Your pharmacy benefit is the part of your Virginia Premier Elite Plus health insurance that covers medications that are prescribed by your doctor.
Virginia Premier’s health insurance prescription drug benefit is administered by Envision Pharmaceutical Services. The customer service team at Envision Pharmaceutical Services can help answer any questions you may have about your prescription or Over-the-counter (OTC) drugs.
You can reach someone at Envision Pharmaceutical Services, 24 hour hours a day 7 days a week.
Q: Will Virginia Premier pay for my prescription?
You can find out what prescriptions may be covered by your pharmacy benefit by looking at the RxGRP on your Member ID card.
If you are eligible for Medicare (Dual Eligible) your prescription medications should be covered by your primary prescription plan. If you have RxGRP: VAPRDUAL, then Virginia Premier Elite Plus may cover your over-the-counter (OTC) medication(s). You can find out if your OTC medication is covered by using the searchable formulary or by searching the downloadable Medicaid Wrap Formulary.
If you are not eligible for Medicare and your RxGRP is VAPRNOND, you can find out if your medication is covered by using Virginia Premier’s searchable formulary or by searching the downloadable formulary. A formulary, or Common Core Formulary, is a list of medications that are covered by Virginia Premier Elite Plus.
Q: Are over-the-counter (OTC) medications covered?
Many generic over-the-counter (OTC) medications are a covered benefit. For more information on OTC drugs covered by Virginia Premier Elite Plus, please visit the formulary resources above under ‘Will Virginia Premier pay for my prescription?’
Q: How much will my prescription or OTC cost?
If your medication is covered, there is no cost to you.
Q: What is prior authorization?
Sometimes a drug requires a prior authorization. In those cases, your doctor must provide medical information to support 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, tell your doctor. Your doctor should contact EnvisionRx to get the drug covered for you.
Q: How to request an Exception / Prior Authorization
Some drugs require a prior authorization before Virginia Premier Elite Plus will cover the cost.
You or your doctor can request a prior authorization by:
- Calling EnvisionRx at 1-844-838-0711 (TTY users call 711), 24 hours a day, 7 days a week.
- Faxing a prior authorization form to EnvisionRx at 877-503-7231.
Prior authorizations can be also be obtained electronically through the Envision PromptPA tool.
NOTE: Virginia Premier Elite Plus members will need to add ‘*VPEPLUS’ to the end of the member ID number when using the Envision PromptPA tool. For example:12345678912*VPEPLUS
Q: What if prior authorization for my drug gets denied?
If your doctor’s request for prior authorization is denied, Virginia Premier will send you and your doctor a letter informing you why it was denied and how to appeal the decision if necessary. View more information about appeals.
The Medication Therapy Management (MTM) Program is part of the Virginia Premier Elite Plus plan benefit, and is no cost to members with multiple health conditions and who take multiple medicines. The MTM program is only available to NONDUAL members, or members who are not eligible for Medicare. The MTM Program is aimed in helping members and doctors make sure the medications are working to help with complex health needs. Participation includes community pharmacists, and in-person/telephonic interventions with trained pharmacists.
How do I benefit from MTM?
- Each medication prescribed is reviewed by an MTM trained pharmacist
- This review provides you the best benefit from your medications
- Decreases the likelihood of adverse side effects
- You will be presented with a Comprehensive Medication Review (CMR) at least annually
How will I be contacted and offered MTM services?
Virginia Premier has contracted with Envision Pharmaceutical Services to deliver MTM services to eligible members. Members eligible for the MTM program will be identified and auto-enrolled on a quarterly basis. If the member is under 18 years of age, or has physical/cognitive impairments, a beneficiary/caregiver will serve as point of contact. If you would like more information or do not want to take part in the program, please call Envision Pharmaceutical MTM Department at 1-866-342-2183 (TTY: 711), Monday through Friday from 9:00am to 5:00pm.
We offer this program to members who meet certain criteria established by the Centers for Medicare and Medicaid Services (CMS), which include:*
- Having three or more chronic health problems. Chronic health problems may include:
- Dyslipidemia (high cholesterol)
- Hypertension (high blood pressure)
- Chronic lung disease (example: asthma or COPD)
- Mental health disorder (example: depression, schizophrenia, bipolar)
- Taking five or more daily medications including non-prescription medication
- Medication costs
How does the MTM program work?
If you qualify for the program, we will mail you a cover letter and a personal medication record (PMR), then a pharmacist will follow up by calling you. This one-on-one conversation by phone may take up to 30 minutes.
A highly-trained pharmacist will review all the prescription drugs, over-the-counter (OTC) medications, dietary supplements, and herbal products you use to identify potential drug-drug interactions, possible adverse effects of medications, or gaps in care. The pharmacist will develop a prioritized list of medication-related problems – or Targeted Medication Reviews (TMR) – and may contact your doctor by mail if any issues were identified with your medications.
An ongoing medication review will continue until the end of the calendar year, and it will be re-evaluated annually. Reviews will occur:
- Once every 3 months, you will be contacted via mail or phone for a review.
- Your primary care provider will receive a patient medication list along with any identified potential therapy care gaps for that member as identified in the applicable quarter.
- Prescribers will be re-notified regarding any unresolved therapy care gaps no more frequently than every 6 months.
What will I Receive?
- Letter indicating eligibility and enrollment in the MTM program
- Personal medication record (PMR) – a list of all the medicines that the member is taking and the reasons for their use
- Complete Medication Review (CMR) – conducted by a pharmacist to review all the prescription drugs, OTC medications, dietary supplements, and herbal products the member uses
*Criteria subject to change
Q: Are my diabetic supplies covered?
Test strips, lancets, meters, control solutions and insulin pump supplies are covered under Virginia Premier Elite Plus. All require a prescription from a doctor. Insulin, syringes and alcohol swabs are also covered under the pharmacy benefit with a prescription.
Our preferred brand for meters (Glucometers) are Abbott and Bayer. Test strips, lancets, and control solutions are covered under the pharmacy benefit at your local pharmacy. A member can receive a free meter of their choice from Abbott by calling 1-866-224-8892 or from Bayer by calling 1-800-401-8440.
Insulin pumps are subject to Medical Necessity and available through DME (Durable Medical Equipment) vendors.
Virginia Premier has a Patient Utilization Management & Safety (PUMS) program to help ensure that members are receiving appropriate health care with a focus on patient safety. Learn more about the PUMS Program.
Q: What are specialty drugs?
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.
Q: Do I need authorization for a specialty drug?
In most cases, yes. Most specialty drugs require prior authorization whether self-administered, administered in a doctor’s office, or administered by a home health service. Authorizations are based on medical need, which is determined by the drug policy, evidence-based medicine, state benefits, regulations, contracts and medical judgment.
Your provider may obtain approval for Specialty drugs by either:
- Calling Envision Pharmaceutical Services at 1-844-838-0711 (TTY users call 711), 24 hours of day, 7 days a week.
- Faxing a prior authorization form to Envision Pharmaceutical Services at 1-877-503-7231.
- Requesting through an electronic PA portal
Once we have prior authorization and the specialty drug is approved, your provider will be informed about the options for specialty drugs:
- Preferred Specialty vendor or pharmacy
- Using office stock
- Options for home health nursing services
Q: Where can I get specialty drugs filled?
Virginia Premier has a network of specialty pharmacies that can make sure you receive your medications safely. To determine what specialty pharmacy you should use, please contact Member Services at 877-719-7358 or EnvisionRx at 1-844-838-0711.