Virginia Premier Health Insurance Pharmacy Benefits


You can reach someone at EnvisionRxOptions 24/7.

Call: 1-855-872-0005
Fax: 1-877-503-7231

Your pharmacy benefit is the part of your Virginia Premier health insurance that covers medications that are prescribed by your doctor.

Virginia Premier’s health insurance prescription drug benefit is administered by EnvisionRxOptions. The customer service team at EnvisionRxOptions can help answer any questions you may have about your prescription drugs.

Will Virginia Premier pay for my prescription?

Q: Will Virginia Premier pay for my prescription?

You can find out if your medication is covered by using Virginia Premier’s searchable formulary below. A formulary, or Preferred Drug Listing (PDL), is a list of medications that are covered by Virginia Premier.

Simply type in the name of your medication and click ‘search.’ You may see notes displayed by your medication name that indicate authorization is required for coverage.

  • PA means that the drug requires prior authorization
  • ST means that the drug requires step therapy, or the trial of alternative drugs first
  • QL means that the drug has a quantity limit
Q: How much will my prescription cost?

Please click here to view the prescription drug co-payment amounts based on plan benefit.

Note: Because of frequent changes in the price of medications, financial information provided may not be exact. Prescription copays are subject to change. Please call EnvisionRxOptions at 855-872-0005 with any questions.

Where can I get my prescriptions filled?

Q: Where can I get my prescriptions filled?

Virginia Premier has a large network of pharmacies available for you to use.  Soon you will be able to look up pharmacies with our Provider Directory.  If you need help finding a pharmacy, please contact us at 800-727-7536.

Prior Authorization

Q: What is prior authorization?

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, tell your doctor. Your doctor should contact EnvisionRxOptions to get the drug covered for you.

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. For more information on appeals, please click here.

Request an Exception / Prior Authorization

Request an Exception / Prior Authorization

Some drugs require a coverage determination or prior authorization before Virginia Premier Health Plan 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.

Prior authorizations can be obtained through the Envision PromptPA tool below or to open in a new browser window here. If the window doesn’t open right away, check for a Pop-up blocker that is stopping it or hold the key while you click the link.

NOTE: Virginia Premier Medallion 3.0 and FAMIS (Medicaid) members will need to add ‘*VPHP’ to the end of the member ID number when using the Envision PromptPA tool. For example: Medicaid members: 12345678912*VPHP

Envision PromptPA tool

Patient Utilization Management and Safety (PUMS) Program

Virginia Premier Health Plan (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.

PUMS Program Goal:

The focus is on patient safety and is not limited to just prescription benefits. Under the PUMS program, members that meet certain clinical criteria will be evaluated to see if the member should be placed into the PUMS program for utilization management and care coordination to ensure appropriate and safe health care.

If a member uses more than appropriate and safe health care services, Virginia Premier looks to see if the PUMS program is right for them. The member may not need to be put into the program. For example, if a member is often going to the ER, for non-emergency use, that member may just need a doctor with longer business hours. For members in the PUMS program, Virginia Premier takes extra steps to make sure they use services appropriately and safely.

How do People Become PUMS Members? There are two ways for a member to be placed in the PUMS program:
  • At the suggestion of a health care worker or by social services, and/or
  • By looking at the services the member receives. Virginia Premier has standards that alert them to whether a member might be getting inappropriate and /or unsafe services.
Being considered for PUMS does NOT mean a member has done something wrong.

For any member who may be at risk for inappropriate and/or unsafe services, Virginia Premier must evaluate whether the member should be enrolled in the PUMS program. In cases involving use of the prescription drug buprenorphine, the member will automatically be enrolled in PUMS.

How Might PUMS Change a Members’ Care?

Virginia Premier will coordinate health care to help ensure appropriate and safe health care services for the member. For example, Virginia Premier could set a single doctor or pharmacy to serve the member for controlled substances.
PUMS Member Rights: Virginia Premier will send every PUMS member a letter about the program. The letter will make clear how the member can get emergency care. The letter will also tell them how they can appeal being placed in the PUMS program.

PLEASE NOTE: Virginia Premier’s doctors and pharmacists now use the Prescription Monitoring Program (PMP). The PMP helps them make sure that prescription drugs are used the right way.

What is the Prescription Monitoring Program (PMP)?

The PMP keeps a record of who is being given controlled substances (prescription drugs), and how much. Using the PMP, Virginia Premier can find out who is getting the drugs they’re supposed to get, and help people in programs such as PUMS. The PMP was set up by the Department of Health Professions.

Any data linked to the PMP is treated as confidential.

Over-The-Counter Medications

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, click here.


OTC medications are NOT a covered benefit for FAMIS members except for the following: Omeprazole, Loratadine, Cetirizine, Ketotifen, and Permethrin.

Are my diabetic supplies covered?

Q: Are my diabetic supplies covered?

Test strips, lancets, meters, control solutions and insulin pump supplies are covered under Virginia Premier Health plan. All require a prescription from your doctor. 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 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 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.

Specialty Drugs

Q: Does Virginia Premier cover Specialty Drugs?

Your doctor may request a “Specialty” drug. “Specialty” drugs are high-cost medications used to treat complex or long-term conditions like cancer, hepatitis, hemophilia, etc.

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. Authorizations are based on medical need, which is determined by the drug policy, evidence-based medicine, state benefits, regulations, contracts and medical judgment.

Your doctor may obtain approval for Specialty drugs by calling EnvisionRxOptions at 855-872-0005.

Your doctor may also obtain approval for Specialty drugs by faxing a prior authorization form to EnvisionRxOptions at 877-503-7231.

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
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.

A general list of our preferred vendors and the drugs they provide can be found here.

A more detailed list that includes specific specialty drugs and where they should be filled can be found here.

FAMIS Mail Order Prescriptions

Virginia Premier Health Plan FAMIS members have access to our mail order prescription benefit through Costco Pharmacy. For more information or to order a refill on an eligible mail order prescription online, please visit Costco Mail Order Pharmacy.

Download the Costco Mail Order Brochure and Order Form.

Note: Mail Order is NOT a covered benefit for Medallion 3.0 members.

Identify Safety Concerns

For information about drug side effects or potential drug interactions, visit the website of our Prescription Benefit Manager, EnvisionRxOptions: Learn more about specific medications.

Note: You will need to click “Learn more about specific medications” in the ‘Health and Drug Information’ section (lower left content panel) of the EnvisionRx page after following the above link.

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

You can reach EnvisionRxOptions 24/7 by calling 855-872-0005.

You can reach the Virginia Premier Pharmacy Department Monday through Friday, 8am-5pm, at 800-727-7536 x77121.

Additional Information

Additional Information The documents listed below can give you more specific information on Virginia Premier’s health insurance preferred drug listing and drugs that need prior authorization.