Prescription Drug Coverage Determination Request (Prior Authorization)

Some drugs require a coverage determination (review) before Virginia Premier CompleteCare will cover the cost. Use the Envision online tool below to ask for a drug coverage determination. This form can be filled out by a member, a member’s appointed representative or the prescribing doctor/provider.

NOTE: Virginia Premier CompleteCare members will need to add ‘*VPHPPARTD’ to their member ID number.
For example: 1234567*VPHPPARTD

H3067_040115WEB CMS Approved