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VA
Virginia Prior Authorization Requirements
Medicaid MCODual-EligibleMedicare TraditionalMedicare AdvantagePart DMedicaid FFSCommercial (employer / fully-insured)
PA required
64%
215 verified rules
Verified May 13, 2026
Service category PA
All programs combinedSpecialty Drugs
5/6Conditional
Durable Medical Equipment
5/6Conditional
Mental Health — Inpatient
4/6Conditional
Inpatient Hospital
4/6Conditional
Skilled Nursing Facility
4/6Conditional
Home Health
4/6Conditional
Outpatient Surgery
4/6Conditional
Substance Use Treatment
3/6Conditional
Occupational Therapy
3/6Conditional
Diagnostic Imaging
3/6Conditional
Ambulance Transport
3/6Conditional
Physical Therapy
3/6Conditional
Speech Therapy
3/6Conditional
advanced_imaging
3/6Conditional
Laboratory
0/6No PA
Drug class PA
Part D federal protections flaggedImmunosuppressants
6/8Conditional
Rare Disease / Orphan
6/7Conditional
ADHD Stimulants
5/6Conditional
Brand (No Generic)
5/6Conditional
Antipsychotics
5/7Conditional
Biosimilars
5/6Conditional
Specialty Biologics
5/6Conditional
Brand (Generic Available)
5/6Conditional
Controlled — Schedule III–V
5/6Conditional
Controlled — Schedule II
5/6Conditional
Diabetes — Non-Insulin
5/6Conditional
Hepatitis C
5/6Conditional
Specialty Non-Biologic
5/6Conditional
Diabetes — Insulin
5/6Conditional
Oral Oncology
4/6Conditional
Antidepressants
4/6Conditional
HIV Antiretrovirals
4/6Conditional
GLP-1 (Weight Loss)
2/6Conditional
glp1_diabetes
1/1Full PA
Compounded Medications
0/6No PA
Opioid Treatment (MOUD)
0/6No PA
PA type breakdown
Conditional
84
Full PA
50
clinical_criteria
4
Federal protected classes requiring PA
Oral OncologyPA required
AntidepressantsPA required
AntidepressantsPA required
ImmunosuppressantsPA required
HIV AntiretroviralsPA required
AntipsychoticsPA required
Oral OncologyPA required
AntipsychoticsPA required
HIV AntiretroviralsPA required
ImmunosuppressantsPA required
State flags
Medicaid expansion state
WISeR pilot (high data quality)
FFS-dominant (minimal MCO)
Look up a specific PA rule for Virginia
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