Finding a Drug
Questions?
You can reach someone at Virginia Premier 24/7.
- Call: 1-800-727-7536
- Fax: 1-833-770-7569
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.
Frequently Asked Questions
Q: How can I determine if a medication is covered?
You can find out if a medication is covered using Virginia Premier’s drug search tool here.
If you are unsure if your patient is a Virginia Premier member, please call Member Services at 800-727-7536.
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 link above to search the drug list.
Q: How much will the prescription cost?
For Medicaid members, covered drugs are $0.
Q: Where can my patients get prescriptions filled?
Virginia Premier has a large network of pharmacies available for you to use. To find a pharmacy near you, please visit the link above to search the pharmacy directory or visit our Provider Directory. If you need additional help finding a pharmacy, please contact us at 800-727-7536.
Q: What is my patient paid out of pocket for a prescription?
Whenever possible, members should always contact Member Services 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, members may have to pay the full cost of the prescription when you pick it up. If this happens, members can ask us for a reimbursement. Reimbursement is not guaranteed and may depend on your 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:
- Instructions for Pharmacy Reimbursement
Q: How do I request an exception or prior authorization?
Some drugs require a prior authorization before Virginia Premier will cover the cost.
- Calling Virginia Premier at 1-800-727-7536 (TTY:711), Monday through Friday, 8:00 a.m. to 6:00 p.m.
- Faxing a prior authorization form to Virginia Premier at 1-833-770-7569
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 click here. If you would like to discuss a specific denial, call us at 1-800-727-7536.
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.
The Medication Therapy Management (MTM) Program is part of the Medicaid Benefit and is no cost to members with multiple health conditions and who take multiple medications. The MTM Program is aimed at 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.
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
DMAS is pleased to announce that a new permanent policy allowing coverage of a maximum of a 90 day supply of many maintenance drugs will be implemented on 10/1/2021. The list of eligible maintenance drugs has been developed to include many highly utilized medications on the DMAS Preferred Drug List which members typically receive for long term therapy. Members will be eligible for this policy after receiving two 34-day or shorter fills of drugs on this list. This new maintenance list is not all inclusive. If your medication is not on the maintenance list, you may receive a maximum 34-day supply of your prescriptions.
The 90 Day Maintenance Listing can be found here.
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 may obtain approval for Specialty drugs by either:
- Calling Virginia Premier at 1-800-727-7536, Monday through Friday 8 a.m. to 6 p.m.
- Faxing a prior authorization form to Virginia Premier at 1-833-770-7569.
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 you receive your medications safely. To determine what specialty pharmacy you should use, please contact Member Services at 800-727-7536.
