Virginia Medicaid PDL Program
Service Authorization(SA) RequestsPDL
- Ampyra SA Form
- Effient Service Authorization Form
- Ketek PA Request Form
- Long Acting Narcotics SA Form
- Narcotic Lozenge SA Form
- Proton Pump Inhibitors (PPI) SA Request Form
- PDL SA Request Form
- PDL & Criteria (effective 1/1/12)
- PDL & Criteria (effective 10/19/11)
- PDL & Criteria (effective 7/1/11)
- PDL Quick List (effective 5/11/11)
- PDL Criteria (effective 5/11/11)
- PDL Quick List (effective 2/23/11)
- PDL Criteria (effective 2/23/11)
- PDL Quick List (effective 01-01-11)
- PDL Criteria (effective 01-01-11)
- PDL Quick List (effective 09-01-10)
- PDL Criteria (effective 09-01-10)
- PDL Quick List (effective 07-01-10)
- PDL Criteria (effective 07-01-10)
- PDL Quick List (effective 04-01-10)
- PDL Criteria (effective 04-01-10)
- PDL Quick list (effective 01-01-10)
- PDL Criteria (effective 01-01-10)
- PDL Quick list (effective 07-01-09)
- PDL Criteria (effective 07-01-09)
- PDL Quick list (effective 04-21-2009).
- PDL Quick list (effective 01-01-09)
- PDL Criteria (effective 01-01-09)
- PDL Quick list (effective 10-24-08)
- PDL Quick list (effective 09-9-08)
- PDL Quick list (effective 07-1-08)
- PDL Criteria (effective 07-01-08)
- PDL Quick list (effective 01-1-08)
- How to download the PDA Quicklist
- PDL Appeals Process1/08/2004)
- PDL 72 Hour Policy (1/08/2004)