Virginia Premier’s pharmacy benefit covers medications for your patients.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 regarding medication coverage.
You can reach someone at EnvisionRx 24/7
- Call: 1-855-872-0005
- Fax: 1-877-503-7231
For general information about the development of our formulary, please review the Overview of the Formulary.
Forms & Documents
All of our pharmacy forms and documents can be found in our Provider Document library.
Q: How can I determine if a medication is covered?
You can find out if a medication is covered by using Virginia Premier’s searchable formulary.
For Medallion 4.0 FAMIS members, you can find out if your medication is covered by using Virginia Premier’s searchable formulary or, you can find out if a drug is covered by searching the downloadable formulary.
If you are unsure if your patient is a Medallion 4.0 member, please call Member Services at 800-727-7536, or EnvisionRx at 855-872-0005 for help.
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 the 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 co-pays are subject to change. Please call EnvisionRx at 855-872-0005 with any questions.
Q: Where can my patients get prescriptions filled? Virginia Premier has a large network of pharmacies available to use. Please visit our Provider Directory to find a pharmacy near you. If you need help finding a pharmacy, please contact Member Services at 800-727-7536.
Q: What is my patient paid out of pocket for a prescription?
Whenever possible, members should always contact Member Services or EnvisionRx right away if faced with paying out of pocket for a prescription so we can help.
If the pharmacy is not able to get the necessary information to process the prescription, or the medication is not covered, members may have to pay the full cost of the prescription. If this happens, members can ask us for a reimbursement. Reimbursement is not guaranteed and may depend on eligibility and/or drug coverage. Check the drug list (formulary) for more information.
To ask for reimbursement, members can download the Member Reimbursement Form and follow the directions:
Q: How do I request an exception or prior authorization?
Some drugs require a prior authorization before Virginia Premier will cover the cost.
Prior authorizations can be obtained 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
- Electronically via an electronic prior authorization portal (ePA)
- Using EnvisionRx’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
For Electronic Prior Authorization (ePA) assistance, please review the documents below:
- EnvisionRx Online Coverage Determination Guide
- CoverMyMeds User Guide
- EnvisionRx CoverMyMeds Prescriber Guide
- Surescripts CompletEPA® YouTube Video
Q: What if prior authorization for a drug gets denied?
If your request for prior authorization is denied, Virginia Premier will send you and the member a letter informing you why it was denied and how to appeal the decision if necessary. All appeals for drug medications must be sent to Virginia Premier Grievances and Appeals Department. For more information on appeals, please clickhere. If you would like to discuss a specific denial, call EnvisionRx at 1-855-872-0005.
Test strips, lancets, meters, control solutions and insulin pump supplies are covered under Virginia Premier with a prescription. 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. Members 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.
If you have any questions about plan coverage, please contact Virginia Premier member services at 1-800-727-7536.
Medication Therapy Management (MTM) is offered as part of the Medallion 4.0 plan benefit and is no cost to members. Members may be eligible for the MTM Program if they experience multiple health conditions and take multiple medications. The MTM Program is intended to help members and prescribers ensure medications are working effectively to help with complex health needs. Participation includes in-person and/or telephonic interventions with trained pharmacists, including community pharmacists.
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 primary point of contact.
We offer this program to members who meet or exceed 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:
- Chronic Lung Disease
- Mental health
- Neurologic disorder
- Taking five or more daily medications including non-prescription medication
- Medication drug spend ($600 or greater over a 90 day period).
Note that MTM criteria is subject to change.
Qualified members will receive a letter with the option to call in to complete a Comprehensive Medication Review (CMR) over the phone. There is also capability of a community pharmacist to complete an in-person CMR as well. The pharmacist will review all the prescription drugs, over-the-counter (OTC) medications, dietary supplements, and herbal products used 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 prescriber(s) by mail if any issues have been identified. An ongoing medication review will continue until the end of the calendar year, and will be re-evaluated annually.
Reviews will occur:
- Once every 3 months, members will be contacted via mail or phone for a review.
- Primary care provider(s) will receive a patient medication list, along with any identified potential therapy care gaps for that member, as identified during the applicable quarter.
- Prescribers will be re-notified regarding any unresolved therapy care gaps no more frequently than every 6 months.
Patients will receive
- Letter indicating eligibility and enrollment in the MTM program
- Personal medication record (PMR) – a list of all the medications 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
A CMR vendor portal has been created to extend the Comprehensive Medication Review functionality of the PBM to community pharmacists as well as internal pharmacists. Users who have been contracted by Envision to conduct CMR’s will be granted secure access. This will allow users to locate, schedule, conduct, and record interviews with Virginia Premier plan members. The retail pharmacist would submit the CMR sheet via fax and complete the portal information.
For more information on reimbursement, visit Envision’s online provider portal.
For online portal help, visit Envision’s vendor portal user guide
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.
You 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, you 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?
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.
Virginia Premier has a network of specialty pharmacies that can make sure your patients receive 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 EnvisionPharmacies. 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.
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 call center phone number: 800-361-4542
- Envision MAC Disputes email address: MAC@envisionrx.com
For more information on MAC Dispute Resolution, visit https://envisionrx.com/PrescribersAndProviders/Pharmacies#MACDisputes
EnvisionRx requests that pharmacies provide the information listed below to ensure that requests can be reviewed without any disruption. Once a request for reconsideration is provided to EnvisionRx, 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 EnvisionRx 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
- Drug Strength
- Acquisition Cost
- Contact Name and Number
EnvisionRx 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.