PrescriptionsWe will generally pay for medications on the Formulary. You can find the formularies for all of our plans through our online drug search. We will generally cover these drugs as long as members follow these basic rules:
- The member must have a valid prescription from a provider (a doctor, dentist or another prescriber)
- The prescriber must either accept Medicare or file documentation with CMS showing that he or she is qualified to write prescriptions.
- The member generally must use a network pharmacy to fill their prescription. Our provider search tool can be used to find a network pharmacy.
- The drug must be on our Formulary.
- The drug must be used for a medically accepted indication. A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration (FDA) or supported by certain reference books. (For more information refer to your plan’s Evidence of Coverage.
- Non-prescription drugs (also called over-the-counter drugs)
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Drugs if they are being used to promote fertility; relieve cough or cold symptoms; for cosmetic purposes or to promote hair growth; for the treatment of sexual or erectile dysfunction (such as Viagra, Cialis, Levitra, and Caverject)
Are there any restrictions on a member’s coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: We require the member or physician to get a prior authorization for certain drugs. For more information or details regarding a specific drug, see our downloadable form:
- Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 60 capsules every 30 days for prescriptions of Vraylar Capsules (3mg). This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, we require the member to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Virginia Premier may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. For more information or details regarding a specific Part D drug, see our downloadable form:
- Part B or D Determination: In some cases, the prescription drug may be covered under Medicare Part B or Part D. We require additional information to explain the use and setting of the drug to make the determination.
Part B Drugs and Diabetic SuppliesThe member’s Part B coverage generally doesn’t cover most prescription drugs used at home, but it does cover a limited number of outpatient prescription drugs under limited conditions. Members may obtain some Part B drugs through a pharmacy with a valid prescription from their provider. In some cases, the drug may be covered under Part B or Part D. We require additional information to explain the use and setting of the drug to make the determination. You can find more information about coverage determinations on the Coverage Determination page. Test strips, lancets, meters and control solutions are covered under the member’s Part B benefit with Virginia Premier. All require a prescription from a prescriber and can be filled through a pharmacy. Our preferred vendors for meters (glucometers) are Abbott and Bayer.
Drugs covered by Part B:
- Drugs used with an item of durable medical equipment (i.e. nebulizer, glucose monitoring);
- Some antigens;
- Injectable osteoporosis drugs;
- Erythropoiesis-stimulating agents;
- Blood clotting factors;
- Injectable and infused drugs;
- Oral End-Stage Renal Disease (ESRD) drugs;
- Parenteral and enteral nutrition;
- Intravenous Immune Globulin (IVIG) provided in the home;
- Some Vaccines such as Flu, Pneumococcal, and Hepatitis (Click here for information on billing for Part D Vaccines)
- Transplant drugs (immunosuppressive drugs)
- Oral cancer drugs;
- Oral anti-nausea drugs
Specialty Part D Drugs
Specialty Part D Drugs are high-cost injectable, infused, oral or inhaled medications that are typically prescribed to treat chronic or long-term conditions that have few or no alternative therapies, such as cancer, HIV/AIDS, Hepatitis C, Multiple Sclerosis, and others. Members who take specialty drugs require customized clinical monitoring and support to reduce their health risks and potentially serious side effects.
We have designated Envision Specialty Pharmacy to provide specialty drugs to our members.
For information, or to start the filling process, visit Envision Specialty Pharmacy’s webpage.
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: 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: Envision Provider 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
- 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 frequently than every 7 days.
Transition Fill Policy
Our transition fill policy meets the immediate needs of our valued members. It allows the member sufficient time to work with his or her prescribing physician to switch to a therapeutically equivalent formulary medication, or to complete the coverage determination process.
Medication Therapy Management (MTM) program
The Medication Therapy Management (MTM) Program is not considered a part of the plan’s benefit but is no cost to members with multiple health conditions and who take multiple medications. The MTM Program aims to help members and doctors make sure the medications are working to help with complex health needs.
Virginia Premier has contracted with Envision Pharmaceuticals Services to deliver MTM services to eligible members. If you would like more information, please call Envision Pharmaceutical MTM Department at 1-866-342-2183 (TTY: 711), Monday through Friday from 9:00 am to 5:00 pm.
MTM Program Eligibility
Members eligible for the MTM program will be identified and auto-enrolled on a quarterly basis. We offer this program to members who meet 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:
- Alzheimer’s Disease
- Bone Disease – Arthritis – Osteoporosis
- Respiratory Disease – Chronic
- Taking eight or more daily Part D medications.
- Spending $3,967 or more per year on Part D covered medications. Membership is per the calendar year and is re-evaluated annually.
How does the MTM program work?
If the member qualifies for the program, we will mail the member a cover letter and a personal medication record (PMR), then a pharmacist will follow up by calling the member. This one-on-one conversation by phone may take up to 30 minutes.
A highly-trained pharmacist will review all the prescription drugs, over-the-counter (OTC) medications, dietary supplements, and herbal products the member uses 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 (TAR) – and may contact the doctor by mail if any issues were identified with your medications.
An ongoing medication review will continue until the end of the calendar year, and it will be re-evaluated annually. Reviews will occur:
- Once every 3 months, the member will be contacted via mail or phone for a review.
- The primary care provider will receive a patient medication list along with any identified potential therapy care gaps for that member as identified in the applicable quarter.
- Prescribers will be re-notified regarding any unresolved therapy care gaps no more frequently than every 6 months.
What will MTM Members receive?
Each enrolled MTM member will receive:
- a cover letter indicating eligibility and enrollment in the MTM program;
- a personal medication record (PMR) – a list of all the medicines that the member is taking and the reasons for their use;
- a Complete Medication Review (CMR) conducted by a pharmacist to review all the prescription drugs, OTC medications, dietary supplements, and herbal products the member uses;
- General educational information.