Pharmacy Benefits for Premier Health Insurance in Virginia


You can reach someone at EnvisionRxOptions 24/7.

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

Virginia Premier’s pharmacy benefit covers prescription medications for your patients.

Virginia Premier’s prescription drug benefit is administered by EnvisionRxOptions. The team at EnvisionRxOptions can help answer any questions you may have regarding medication coverage.

Overview of the Formulary

Forms & Documents

All of our pharmacy forms and documents can be found in our Provider Document library.

List of Covered Drugs - Formulary

The easiest way to find out if a prescription drug is covered is to use Virginia Premier’s searchable formulary below. Simply type in the name of your medication and click ‘search.’ A complete, downloadable formulary can be found in our Provider Document library. Notes displayed by the medication name in the searchable formulary will indicate if that drug requires prior authorization, step therapy, or has a quantity limit. If you have any questions about the formulary or covered drugs, please contact EnvisionRxOptions at 855-872-0005.

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.

How can I obtain prior authorization for a medication?

If your patient’s medication requires prior authorization, please contact EnvisionRxOptions to submit information for approval. Necessary forms can be found in our Document Library

Prior authorization forms can be faxed to EnvisionRxOptions at: 877-503-7231.

Prior authorizations can also be handled by phone with EnvisionRxOptions at: 855-872-0005.

For electronic prior authorization (EPA) assistance, please review the documents below:

  • Surescripts CompletEPA® Webinar – Take the pain out of Medication Prior Authorizations
  • Surescripts CompletEPA® YouTube video
  • Prior authorizations can also be initiated online through Envision’s coverage determination tool, PromptPA, below or to open in a new browser window here. This form can be filled out by a member, a member’s appointed representative or the prescribing doctor/provider. If the window doesn’t open right away, check for a Pop-up blocker that is stopping it or hold the “ctrl” 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

    Visiting PromptPA

    What if my request for prior authorization gets denied?

    If your request for prior authorization is denied, Virginia Premier will send you and your patient a letter informing you why it was denied and how to appeal the decision if you choose to do so. For more information on appeals, please click here.

    Are over-the-counter (OTC) medications covered for my patients?

    Many essential and routine generic over-the-counter (OTC) medications are a covered benefit. To download a list of OTC drugs covered by Virginia Premier, click here.

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

    Are diabetic supplies covered for my patients?

    Test strips, lancets, meters, control solutions and insulin pump supplies are covered under Virginia Premier Health plan. All require a prescription from a prescriber. Insulin, syringes and alcohol swabs are also covered under the pharmacy benefit at local pharmacies with a prescription.

    Our preferred vendors for meters (Glucometers) are Abbott and Bayer. Strips, lancets, and control solutions are covered under the pharmacy benefit at your local pharmacy. Your patient can receive a free meter of 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

    Do specialty drugs require prior authorization?

    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.

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

    You will be informed of the options for specialty drugs when we have prior authorization and the specialty drug is approved. The options are:

    • Preferred Specialty vendor or pharmacy
    • Using office stock
    • Options for home health nursing services
    Where can my patient get an approved specialty drug filled?

    Virginia Premier has a network of specialty pharmacies that provide specialty drugs for our members. These specialty pharmacies have dedicated pharmacists, nurses, and care coordinators that provide excellent customer service while making sure members receive 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.

    Pharmacy Provider MAC Dispute Resolution

    Pharmacies may contact Virginia Premier’s Pharmacy Benefits Manager (PBM), Envision Rx, regarding MAC pricing reconsiderations. Envision can be contacted by email and/or by phone:

    Envision MAC Disputes email address:

    Envision call center phone number: 800-361-4542

    Provider access to their specific MAC list is available by request via the Envision Provider Portal: support

    Envision requests that pharmacies provide the following information (listed below) to ensure that requests can be reviewed without any disruption. Once a request for reconsideration is provided to Envision, the disputes team completes market research and will respond to each reconsideration request within 4 business days. If MAC pricing is deemed to be inappropriate as a result of a successful appeal, the pricing will be updated within 5 days. If MAC pricing is deemed appropriate, the Envision denial process will include the reason for denial and, if necessary based on the appeal, the NDC for the lower cost product which substantiates the MAC cost.

      Information requested for submission:
    • NCPDP Number
    • Rx Number
    • Date of Fill
    • Qty. Dispensed
    • NDC
    • Drug Strength
    • Acquisition Cost
    • Contact Name and Number
    Envision reviews market prices on a continuous basis. Updates to MAC pricing can occur as frequently as daily, but no less frequent than every 7 days.
    Additional formulary documents, pharmacy information, and authorization forms can be found in our Provider Forms Library.