Your pharmacy benefit is the part of your Virginia Premier health insurance. It covers medications that are prescribed by your provider.
Virginia Premier’s health insurance prescription drug benefit is administered by EnvisionRx. The customer service team at EnvisionRx can help answer any questions you may have about your prescription drugs.
You can reach someone at EnvisionRxOptions 24/7.
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.
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, visit the searchable formulary link above.
Note: OTC medications are NOT a covered benefit for FAMIS members, except for the following: Omeprazole, Loratadine, Cetirizine, Ketotifen and Permethrin.
Q: How much will my prescription cost?
For Medallion 4.0 members, prescription co-pays apply as follows:
|up to 34-day supply||35-90 day supply|
|FAMIS < 150%||$2||$4|
|FAMIS > 150%||$5||$10|
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.
Q: Where can I get my prescriptions filled?
Virginia Premier has a large network of pharmacies available for you to use. Please visit our Provider Directory to find a pharmacy near you. If you need help finding a pharmacy, please contact us at 800-727-7536.
Q: What if I paid out of pocket for my prescription?
Whenever possible, always contact Member Services or EnvisionRx right away if you are faced with paying out of pocket for your prescription so 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 our share. Reimbursement is not guaranteed and may depend on your eligibility and/or drug coverage. Check the drug list (formulary) for more information.
To ask us to pay you back, download the Member Reimbursement Form and follow the directions.
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 EnvisionRx 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 EnvisionRx at 855-872-0005, 24 hours of day, 7 days a week
- Faxing a prior authorization form to EnvisionRx at 877-503-7231
- Using Envision’s online tool, PromptPA. 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 4.0 members will need to add “*VPM4” to the end of the member ID number when using the EnvisionRx PromptPA tool. For example: 12345678912*VPM4
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. For more information on appeals, please click here here.
The Medication Therapy Management (MTM) Program is part of the Medallion 4.0 plan benefit, and is no cost to members with multiple health conditions and who take multiple medicines. 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 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 by clicking here.
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 EnvisionRx at 855-872-0005, 24 hours of day, 7 days a week,
- faxing a prior authorization form to EnvisionRx at 877-503-7231, or
- requesting through an electronic PA system, such as PromptPA or CoverMyMeds.
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 800-727-7536 or EnvisionRx at 855-872-0005.
Virginia Premier Health Plan FAMIS members have access to our mail order prescription benefit through EnvisionPharacies. For more information or to order a refill on an eligible mail order prescription online, please visit EnvisionPharmacies’ website.
Note: Mail Order is NOT a covered benefit for Medallion 4.0 members.
For information about drug side effects or potential drug interactions, visit the website of our Prescription Benefit Manager, EnvisionRx: Learn more about specific medications here.
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 EnvisionRx 24/7 by calling 855-872-0005.
You can reach the Virginia Premier Pharmacy Department Monday through Friday, 8am – 5pm, at 855-813-0363.