CCC Plus Provider Resources – Pharmacy

You can find out what prescriptions may be covered by the member’s pharmacy benefit using the search tools above, or looking at the RxGRP on your member’s ID card.

If the member is eligible for Medicare (Dual Eligible), the prescription medications should be covered by their primary Part D prescription plan. If the RxGRP is: VAPRDUAL, then Virginia Premier Elite Plus may cover the member’s over-the-counter (OTC) medications. If the member is not eligible for Medicare and the RxGRP is VAPRNOND, you can find out if their medication is covered by using Virginia Premier’s drug search tool and download a list of covered drugs.

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 Elite Plus, please visit the formulary resources above.

Q: How much will prescriptions or OTC medications cost?

If the medication is covered, there is no cost to the member. Please note that coverage of an OTC medication requires a valid prescription.

Q: How to request an Exception / Prior Authorization
Some drugs require a prior authorization before Virginia Premier Elite Plus will cover the cost. 

Prior authorizations can be obtained by:

• Completing a form and faxing it to Envision Pharmaceutical Services at 1-877-503-7231. You can find some forms under our Document Library;
• Calling Envision Pharmaceutical Services at 1-844-838-0711;
• Electronically via the Envision PromptPA electronic prior authorization portal (EPA)
  • NOTE: Virginia Premier Elite Plus members will need to add ‘*VPEPLUS’ to the end of the member ID number when using the Envision PromptPA tool. For example: Medicaid members: 12345678912*VPEPLUS.

For Electronic PA assistance, please review the documents below:

• Envision Online Coverage Determination Guide
• CoverMyMeds
• CoverMyMeds User Guide
• Envision Rx CoverMyMeds Prescriber Guide
• Surescripts CompletEPA® YouTube Video

Q: What if prior authorization for my 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 Elite Plus Grievances and Appeals Department. View more information about appeals.

If you would like to discuss a specific denial, call Envision Pharmaceuticals Services at 1-844-838-0711.

Medication Therapy Management (MTM) is offered as part of the Virginia Premier Elite Plus plan benefit for NONDUAL members, 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:
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • 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.

MTM Process

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

Provider Reimbursement

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: Are diabetic supplies covered?

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

Our preferred brand for meters (Glucometers) are Abbott and Ascenia (Bayer). Test strips, lancets, and control solutions are covered under the pharmacy benefit at your local pharmacy. A member can receive a free meter of their choice from Abbott by calling 1-866-224-8892 or from Ascensia (Bayer) by calling 1-800-401-8440.

Insulin pumps are subject to Medical Necessity and available through DME (Durable Medical Equipment) vendors.

Q: What are specialty drugs?

Specialty drugs are medications prescribed to treat complex chronic or long-term conditions such as cancer, HIV/AIDS, hepatitis C, multiple sclerosis and others. These conditions usually have few or no alternative therapies. Specialty drugs are complex medications that you can’t typically find at your local retail pharmacy. 

People who take specialty drugs need extra support to lower health risks and potentially serious side effects. The pharmacies that provide specialty medications are experienced, knowledgeable and dedicated to the care of our members.

Q: Do I need authorization for a specialty drug?

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 either:

• Calling Envision Pharmaceutical Services at 1-844-838-0711 (TTY users call 711), 24 hours of day, 7 days a week
• Faxing a prior authorization form to Envision Pharmaceutical Services at 1-877-503-7231. Forms may be available under the Documents Library.
• Requesting through an electronic PA portal

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 the member get specialty drugs filled?

Virginia Premier has a network of specialty pharmacies that can make sure your patient(s) receive medications safely. To determine what specialty pharmacy you should use, please contact Member Services at 877-719-7358 or EnvisionRx at 1-844-838-0711.

Pharmacies may contact Envision Pharmaceutical Services, Virginia Premier’s Pharmacy Benefits Manager (PBM), 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

Envision requests that pharmacies provide the following information to ensure that requests can be reviewed without any disruption.

• NCPDP Number
• Rx Number
• Date of Fill
• Qty. Dispensed
• NDC
• Drug Strength
• Acquisition Cost
• Contact Name and Number

Once a request for reconsideration is provided to Envision, the disputes team completes market research and will respond to each reconsideration request within four business days. If MAC pricing is deemed to be inappropriate as a result of a successful appeal, the pricing will be updated within five 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.

Envision reviews market prices on a continuous basis. Updates to MAC pricing can occur as frequently as daily, but no less frequent than every seven days.