Menu

Pharmacy Benefits for Individual and Family Plan Members

Your pharmacy benefit is the part of your Virginia Premier health insurance.

You can find out if your medication is covered by using Virginia Premier’s online formulary or by searching the downloadable formularyA formulary, or Preferred Drug Listing (PDL), is a list of medications that are covered by Virginia Premier. 

Search for medications you may need and see if your plan covers them.

Some covered drugs may have additional requirements or limits on coverage, which may include:

  • Prior Authorization: Virginia Premier requires you or your physician to get prior authorization for certain drugs. This means that you will need to contact us for approval before you fill your prescriptions. If you don’t get approval, Virginia Premier may not cover the drug. For more information or details regarding a specific drug, log into the member portal.
  • Quantity Limits: For certain drugs, Virginia Premier limits the amount of the drug that we will cover. For example, we will provide 60 capsules per 30 days per prescription for Isentress Tablets 400mg. This may be in addition to a standard one-month or three-month supply.
  • Step Therapy: In some cases, Virginia Premier requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then we will cover Drug B. For more information or details regarding a specific drug, log into the member portal.
  • Age Limit: There are age restrictions for some drugs. If you do not meet the age criteria and do not get approval, we may not cover the drug.

Find out if your drug has additional requirements or limits by using our Drug Search or downloading your plan’s formulary.

Coverage Determination

If a drug prescribed for you has restrictions or limitations, then you can ask that Virginia Premier make a Coverage Determination, which is a formal exception decision as to whether the drug is covered by your health care plan.
A member, member representative or prescribing physician can request or initiate a coverage determination by:

  • Phone: You can call 1-833-626-1350 (TTY 711); 24 hours a day, 7 days a week.
  • Fax: 1-844-503-7231

Note: If you bring your prescription to a pharmacy and you are told that the prescription isn’t covered under your plan, this is not a Coverage Determination.

Virginia Premier has a Patient Safety Monitoring Program (PSMP) in place to ensure members are getting health care treatment that is appropriate and safe. Being considered for PSMP does not mean a member has done anything wrong. Members participating in PSMP may be at risk for unsafe services and will receive extra guidance to make sure they use services safely. 

PSMP Goal

PSMP deals with prescription drugs as well as other kinds of health care, making certain the member is getting treatment that is appropriate and safe. Virginia Premier’s clinical staff reviews our members’ use of health care services to see whether they should be in PSMP. For members in PSMP, Virginia Premier takes extra steps to make sure they use services safely.

Being considered for PSMP does NOT mean a member has done anything wrong. For any member who may be at risk for unsafe services, Virginia Premier must review whether the member should be in enrolled into PSMP. If enrolled, member will be allowed to see one provider and utilize one pharmacy.

PSMP Rights

From prescription drugs to other kinds of health services, our clinical staff reviews every member’s use of health care services to determine whether they belong in this program. PSMP members will receive a letter about the program and how to get emergency care if needed. In addition, the letter will tell them how they can appeal being placed into PSMP.

Note: Our doctors and pharmacists use the Prescription Monitoring Program (PMP) to make sure prescription drugs are used safely. The triggers that are reviewed by Virginia Premier are:

  • High Opioid Dosage (≥ 90 cumulative morphine milligram equivalents (MME) per day over the past 90 days) and ≥ 3 prescribers and pharmacies
  • High opioid usage (≥ 90 cumulative morphine milligram equivalents (MME) per day over the past 90 days) and ≥ 3 prescribers
  • ≥ 5 opioid prescribers
  • ≥ 5 opioid pharmacies

Our approach is to work collaboratively with patients and providers to ensure safe and appropriate use of controlled substances. We utilize and promote:

  • PMP checks
  • Letter to doctor and member
  • Soft and hard pharmacy edits for benzodiazepine and opioid utilization
  • Following CDC opioid guidelines
  • Case management as appropriate

Test strips, lancets, meters, control solutions and insulin pump supplies are covered under Virginia Premier with a prescription from your provider. Insulin, syringes and alcohol swabs are also covered under the pharmacy benefit at your local pharmacy with a prescription.

Insulin pumps are subject to Medical Necessity and available through DME (durable medical equipment) vendors.

Drugs that are administered by a provider in an office, inpatient or outpatient facility, are not covered under the Pharmacy Benefits. These drugs may or may not require authorization under the Medical Benefits. 

Requests for authorization can be made through the Virginia Premier Provider Portal or by calling member services.

For more information about which drugs are covered under Medical Benefits visit our website at VirginiaPremier.com/individual-family/ or by calling our member services at 833-672-8075, Monday through Friday from 8 am to 6pm, Saturdays from 8 am to 2pm.

You can find out if your medication is covered by using Virginia Premier’s online formulary or by searching the downloadable formulary.

X
X