Pharmacy Benefits For Medicaid Members

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Finding a Drug

Using the tools below, you can search for drugs you might need and see if your plan covers them. You can also search for pharmacies in the network near you.

2023 Virginia Premier Medicaid Prescription Drug List

Your pharmacy benefit is the part of your Virginia Premier plan that covers medications prescribed by your doctor. You may reach the customer service team at 1-800-727-7526 (TTY: 711), Monday through Friday, 8:00 a.m. to 6:00 p.m.

*This link takes you to a website that is not owned or operated by Virginia Premier.

Frequently Asked Questions

Q: Will Virginia Premier pay for my prescription?

You can find out if your medication is covered by using the Virginia Premier drug search tool1 to view and download a list of covered drugs. A drug list is a list of medications that are covered by Virginia Premier.

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, go to the drug search tool1.

Q: How much will my prescription cost?

For Medicaid members, covered drugs are $0.

Q: Where can I get my prescriptions filled?

Virginia Premier has a large network of pharmacies available for you to use.  To find a pharmacy near you, go to the pharmacy search tool or visit our Provider Directory.  If you need help finding a pharmacy, please contact us at 1-800-727-7536 (TTY: 711), Monday through Friday, 8:00 a.m. to 6:00 p.m.

Q: What if I paid out of pocket for my prescription?

Whenever possible, always contact Member Services right away if you are faced with paying out of pocket for your prescription. We can help.

If the pharmacy is not able to get the necessary information to process your prescription, or the medication is not covered, you may have to pay the full cost of the prescription when you pick it up. If this happens, you can ask us to pay you back for what you have paid out of pocket. Reimbursement is not guaranteed and may depend on your eligibility and/or drug coverage. Check the drug list for more information.

To ask us to pay you back, please see the instructions and reimbursement form below.

Q: What is prior authorization?

Sometimes a drug requires 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 provider. Your provider should contact us to get the drug covered for you.

Q: How do I request an exception or prior authorization?

Some drugs require a coverage determination or prior authorization before Virginia Premier will cover the cost. There are multiple ways to request an exception or prior authorization. A member, member’s appointed representative, or the prescribing doctor/provider can request a prior authorization by:

  • Calling Virginia Premier at 1-800-727-7536 (TTY:711), Monday through Friday, 8:00 a.m. to 6:00 p.m.
  • Faxing a prior authorization form to Virginia Premier at 1-833-880-7569

Q: What if prior authorization for my drug gets denied?

If your provider’s request for prior authorization is denied, Virginia Premier will send you and your provider a letter informing you why it was denied and how to appeal the decision if necessary. More information on appeals.

The Medication Therapy Management (MTM) Program is part of the Medicaid Benefit and is at no cost to members with multiple health conditions and who take multiple medications. The MTM Program is aimed at 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 Express Scripts 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 the point of contact.

We offer this program to members who meet certain criteria established by the Centers for Medicare and Medicaid Services (CMS), which include:2

  • Having three or more chronic health problems. Chronic health problems may include:
    • Hypertension (high blood pressure)
    • Dyslipidemia (high cholesterol)
    • Asthma
    • Mental Health
    • Neurological Disorder
    • Diabetes
    • HIV
    • COPD (chronic obstructive pulmonary disease)
  • 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.

An MTM specialized 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 three months. You will be contacted via mail or phone for a review. Upon completion, your primary care provider will receive a patient medication list along with any identified potential therapy care gaps as identified in the quarter. Prescribers will continue to be re-notified of any unresolved therapy gaps, no more than every six 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

2: Criteria subject to change.

DMAS is pleased to announce that a new permanent policy allowing coverage of a maximum of a 90 day supply of many maintenance drugs will be implemented on 10/1/2021. The list of eligible maintenance drugs has been developed to include many highly utilized medications on the DMAS Preferred Drug List which members typically receive for long term therapy. Members will be eligible for this policy after receiving two 34-day or shorter fills of drugs on this list. This new maintenance list is not all inclusive. If your medication is not on the maintenance list, you may receive a maximum 34-day supply of your prescriptions.

The 90 Day Maintenance Listing can be found here.

Q: Are my diabetic supplies covered? 

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. Our preferred vendors for meters (glucometers) are Abbott and Ascensia (Bayer). Test strips, lancets, and control solutions are covered under the pharmacy benefit at your local pharmacy. You can receive a free meter of your choice from Abbott by calling 1-866-224-8892, or from Ascensia (Bayer) by calling 1-800-401-8440. Insulin pumps are subject to Medical Necessity and available through DME (durable medical equipment) vendors. Our goal is to provide you with the best care. If you have any questions about your plan coverage, please contact Virginia Premier Member Services at 1-800-727-7536.
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. For more information, download the PUMS Information Sheet (PDF).

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 monitor 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. 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 Virginia Premier at 1-800-727-7536 (TTY:711), Monday through Friday, 8:00 a.m. to 6:00 p.m.
  • Faxing a prior authorization form to Virginia Premier at 1-833-880-7569

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 call member services at 1-800-727-7536 (TTY:711), Monday through Friday. 8:00 a.m. to 6:00 p.m.

For information about drug side effects or potential drug interactions, please talk to your pharmacist or provider. Learn more about specific medications.

Note: You will need to click “Health Information and Resources” and then click “Learn more about specific medications” under the Health and Drug Information section.

If you have questions about medications, please talk to your pharmacist or provider.

You can reach the Virginia Premier Pharmacy Department by calling 1-800-727-7536, Monday through Friday, 8:00 a.m. to 6:00 p.m.

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