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 3.0 members, you can find out if a medication is covered by using Virginia Premier’s searchable formulary or by reviewing the downloadable 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 3.0 member or 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 3.0 members, please click here to view the prescription drug co-payment amounts based on plan benefit.
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 3.0 members will need to add “*VPHP” to the end of the member ID number when using the EnvisionRx PromptPA tool. For example: 12345678912*VPHP
- 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.
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
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
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 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
Note: Mail Order is NOT a covered benefit for Medallion 3.0 or 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 MAC Disputes email address: MACDisputes@envisionrx.com
- Envision call center phone number: 800-361-4542
Provider access to their specific MAC list is available by request via the Envision Provider Portal: Envisionrx.com support
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