Call our Pharmacy Customer Service line, 24 hours a day, 7 days a week.Call: 1-855-408-0010
For questions about MTMP, call the MTMP Hotline directly: 866-342-2183
Your pharmacy benefit is the part of your Virginia Premier CompleteCare (Medicare-Medicaid Plan) a Commonwealth Coordinated Care Plan that covers medications that are prescribed by your doctor.
Commonwealth Coordinated Care by Virginia Premier’s prescription drug benefit is administered by EnvisionRxOptions. The customer service team at EnvisionRxOptions can help answer any questions you may have about your drug benefits. The customer service team is available 24 hours a day, 7 days a week at 1-855-408-0010.
You can view Virginia Premier CompleteCare’s formulary on our Plan Documents page. A comprehensive formulary is a list of medications that are covered by Commonwealth Coordinated Care by Virginia Premier, or a Preferred Drug Listing (PDL). It lists the drugs believed to be a necessary part of a quality treatment program. The plan will generally cover the drugs listed in the formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed.
You may see notes displayed by your medication name that indicate authorization is required for coverage.
In most cases, the plan will pay for prescriptions only if they are filled at the plan’s network pharmacies. A network pharmacy is a drug store that has agreed to fill prescriptions for our plan members. You may go to any of our network pharmacies.
To find a network pharmacy, you can look in the Provider and Pharmacy Directory or contact Member Services or your care manager. You can download a copy of the full Provider and Pharmacy Directory on our Plan Documents page.Show your plan ID card when you fill a prescription
To fill your prescription, show your plan ID card at your network pharmacy. The network pharmacy will bill the plan for our share of the cost of your covered prescription drug. Depending on your prescription, you may need to pay the pharmacy a co-pay.
If you do not have your plan ID card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information.
If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. You can then ask us to pay you back for our share. If you cannot pay for the drug, contact Member Services right away. We will do what we can to help.
To learn how to ask us to pay you back, see Chapter 7, Section B of the Member Handbook, which can be found on our Plan Documents page.
If you need help getting a prescription filled, you can contact Member Services or your care manager.
For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the drugs available through mail-order are drugs that you take on a regular basis for a chronic or long-term medical condition. The drugs available through our plan’s mail-order service are marked as mail-order drugs in our Drug List.
Our plan’s mail-order service allows you to order at least a 90-day supply. A 90-day supply has the same co-pay as a one-month supply.
To get order forms and information about filling your prescriptions by mail, visit www.orchardrx.com. You can also contact Orchard Specialty Pharmacy at 1-877-437-9012 Monday through Friday, 8:00am-10:00 pm, and Saturday, 8:30 am-4:30 pm.
Usually, a mail-order prescription will get to you within 14 days. Our plan will allow for an emergency supply at a retail store if the mail-order is delayed.
Our plan’s mail-order service previously provided members with mail-order drugs using an “automatic refill” service. If you used our “automatic refill” service in the past, we automatically sent you a refill of your drugs when our records indicated that you were about to run out. However, we now need to get your permission before we can send you a refill by mail. We will not need to get your permission to send your drugs by mail when you ask us for the refill or ask us for a new prescription.
This may be a change for you if you have always used mail order in the past and have not needed to tell us to send a refill of your prescription. But this change helps us to make sure you only get drugs you really need.
So that we can make sure that you want a refill, please tell us the best way to reach you. Call Member Services at 1-855-338-6467 to let us know your communication preference. If we don’t know the best way to reach you, you might miss the chance to tell us whether you want a refill and you could run out of your prescription drugs. Remember, your drugs will not be automatically shipped unless you confirm you still want to receive the order. This new policy won’t affect refill reminder programs in which you go in person to pick up the prescription and it won’t apply to long–term care pharmacies that give out and deliver prescription drugs.
Sometimes a drug requires prior authorization. In those cases, your doctor must provide medical information to back up the request for the drug before it will be covered. This additional step helps ensure the drug is being used safely and appropriately.
If your drug requires prior authorization, visit this page or tell your doctor. Your doctor should contact us to get the drug covered for you.
Toll free: 1-855-408-0010. Fax: 1-866-250-5178
If your doctor’s request for prior authorization is denied, Virginia Premier CompleteCare will send you and your doctor a letter informing you why it was denied and how to appeal the decision if necessary. For more information on appeals, please click here.
Specialty drugs are medications prescribed to treat complex chronic or long-term conditions such as cancer, HIV/AIDS, hepatitis C, multiple sclerosis and others. These conditions usually have few or no alternative therapies. Specialty drugs are complex medications that you can’t typically find at your local retail pharmacy.
People who take specialty drugs need extra support to lower health risks and potentially serious side effects. The pharmacies that provide specialty medications are experienced, knowledgeable and dedicated to the care of our members.
In most cases, yes. Authorizations are based on medical need, which is determined by the drug policy, evidence-based medicine, benefits, regulations, contracts and medical judgment.
Your doctor may obtain a request for specialty drugs by calling 1-855-408-0010.
Your doctor may also obtain prior authorization for Specialty drugs by faxing a prior authorization form to 1-866-250-5178.
Once we have prior authorization and the specialty drug is approved, your doctor will be informed about the options for specialty drugs:
- Preferred Specialty vendor or pharmacy
- Using office stock
- Options for home health nursing services
Many generic over-the-counter (OTC) medications and some Non-Medicare Part D prescription medications are a covered benefit. To see what over-the-counter medications are covered under Virginia Premier CompleteCare, please click below or visit our Plan Documents page. For more information on which drugs are covered by Virginia Premier CompleteCare, please see our Formulary (List of Covered Drugs) on our Plan Documents page. Or you can contact Member Services at 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday to Friday. The call is free.
Download the Over-the-counter (OTC) Drug List.
Federal regulations at 42 CFR § 423.800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.
To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate.
For more information, please click here.
Additional Pharmacy Documents
The documents listed below can give you more specific information on your pharmacy benefit.
- List of Covered Drugs (Formulary)
- Member Reimbursement Form
- Prescription Drug Transition Policy
- Step Therapy List
- Prior Authorization List
- Formulary Changes (EOY)
Have Questions? Let’s talk.Call us at 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice). The call is free.
Virginia Premier CompleteCare is a health plan that contracts with both Medicare and the Virginia Department of Medical Assistance Services to provide benefits of both programs to enrollees.
Limitations, copays, and restrictions may apply. For more information, call Virginia Premier CompleteCare Member Services or read the Virginia Premier CompleteCare Member Handbook.
Benefits, List of Covered Drugs, and pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.
You can get this information for free in other languages. Call 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice). The call is free.
You can ask for this information in other formats, such as Braille or large print. Call 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice).
H3067_040115.3.WEB CMS Approved