Virginia Premier’s prescription drug benefit is administered by Express Scripts.
If you have questions or need assistance, our customer service team is available 24 hours a day, 7 days a week, call 1-877-739-1370 (TTY: 711).
Prescriptions
We will generally pay for medications on the Formulary. You can find the formularies for all of our plans through our online drug search. We will generally cover these drugs as long as members follow these basic rules:
- The member must have a valid prescription from a provider (a doctor, dentist or another prescriber)
- The prescriber must either accept Medicare or file documentation with CMS showing that he or she is qualified to write prescriptions.
- The member generally must use a network pharmacy to fill their prescription. Our provider search tool can be used to find a network pharmacy.
- The drug must be on our Formulary.
- The drug must be used for a medically accepted indication. A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration (FDA) or supported by certain reference books. (For more information refer to your plan’s Evidence of Coverage.
By law, the categories of drugs listed below are not covered by Medicare Part D plans, including Virginia Premier:
- Non-prescription drugs (also called over-the-counter drugs)
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Drugs if they are being used to promote fertility; relieve cough or cold symptoms; for cosmetic purposes or to promote hair growth; for the treatment of sexual or erectile dysfunction (such as Viagra, Cialis, Levitra, and Caverject)
- Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale.
Are there any restrictions on a member’s coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: We require the member or physician to get a prior authorization for certain drugs.
For more information or details regarding a specific drug, see our downloadable form: - Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 60 capsules every 30 days for prescriptions of Vraylar Capsules (3mg). This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, we require the member to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Virginia Premier may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
For more information or details regarding a specific Part D drug, see our downloadable form: - Part B or D Determination: In some cases, the prescription drug may be covered under Medicare Part B or Part D. We require additional information to explain the use and setting of the drug to make the determination.
You can find out if your drug has additional requirements or limits by using our Drug Search or downloading the plan’s formulary.
You can ask us to make an exception to these restrictions or limits, also known as a Part D Coverage Determination. You can find more information about coverage determinations on the Coverage Determination page.
Part B Drugs and Diabetic Supplies
The member’s Part B coverage generally doesn’t cover most prescription drugs used at home, but it does cover a limited number of outpatient prescription drugs under limited conditions. Members may obtain some Part B drugs through a pharmacy with a valid prescription from their provider. In some cases, the drug may be covered under Part B or Part D. We require additional information to explain the use and setting of the drug to make the determination. You can find more information about coverage determinations on the Medicare Complaints, Grievances and Appeals page.
Test strips, lancets, meters and control solutions are covered under the member’s Part B benefit with Virginia Premier. All require a prescription from a prescriber and can be filled through a pharmacy. Our preferred vendors for meters (glucometers) and test strips are Abbott and Ascensia (Bayer) and have a $0 copay. Other test strips, lancets, and control solutions may be available under the pharmacy benefit at your local pharmacy with a 20% coinsurance.
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 1-877-739-1370 (TTY: 711).
Drugs covered by Part B:
- Drugs used with an item of durable medical equipment (i.e. nebulizer, glucose monitoring);
- Some antigens;
- Injectable osteoporosis drugs;
- Erythropoiesis-stimulating agents;
- Blood clotting factors;
- Injectable and infused drugs;
- Oral End-Stage Renal Disease (ESRD) drugs;
- Parenteral and enteral nutrition;
- Intravenous Immune Globulin (IVIG) provided in the home;
- Some Vaccines such as Flu, Pneumococcal, and Hepatitis (Click here for information on billing for Part D Vaccines)
- Transplant drugs (immunosuppressive drugs)
- Oral cancer drugs;
- Oral anti-nausea drugs
Medication Therapy Management (MTM) program
The Medication Therapy Management (MTM) Program is not considered a part of the plan’s benefit but is no cost to members with multiple health conditions and who take multiple medications. The MTM Program aims to help members and doctors make sure the medications are working to help with complex health needs.
Virginia Premier has contracted with Express Scripts to deliver MTM services to eligible members. If you would like more information or do not want to take part in the program, please call the Express Scripts MTM Department at 1-844-866-3730 (TTY: 711), Monday through Friday from 9:00 a.m. to 7:00 p.m. Central Standard Time.
MTM Program Eligibility
Members eligible for the MTM program will be identified and auto-enrolled on a quarterly basis. 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:
- Alzheimer’s Disease
- Bone Disease – Arthritis – Osteoporosis
- Diabetes
- Dyslipidemia
- Hypertension
- Respiratory Disease – Chronic
- HIV-AIDS
- Chronic Heart Failure (CHF)
- Taking seven or more daily Part D medications.
- Members may likely incur an annual spend equal to or greater than $4,935 in 2023 for all covered chronic Part D medications.
How does the MTM program work?
If the member qualifies for the program, we will mail the member a cover letter and a personal medication record (PMR), then a pharmacist will follow up by calling the member. 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 the member uses 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 the 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, the member will be contacted via mail or phone for a review.
- The 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 MTM Members receive?
Each enrolled MTM member will receive:
- a cover letter indicating eligibility and enrollment in the MTM program;
- a personal medication record (PMR) – a list of all the medicines that the member is taking and the reasons for their use;
- a Complete Medication Review (CMR) conducted by a pharmacist to review all the prescription drugs, OTC medications, dietary supplements, and herbal products the member uses;
- General educational information.
