Your pharmacy benefit is the part of your Virginia Premier plan that covers medications prescribed by your doctor. Virginia Premier's prescription drug benefit is administered by Envision Pharmaceutical Services. The customer service team is available 24 hours a day, 7 days a week. Advantage Elite members can call 1-855-408-0010 (TTY: 711) and Advantage Gold and Advantage Platinum members you can call 1-844-838-0705 (TTY: 711).
More details on your Pharmacy Benefits can be found in your plan's Evidence of Coverage document.
The plan will generally pay for medications on the Formulary. A formulary is a list of medications that are covered by the plan. It lists the drugs believed to be a necessary part of a quality treatment program. You can find the formularies for all plans with our online drug search. The plan will generally cover these drugs as long as you follow these basic rules:
To fill your prescription, show your plan ID card at the network pharmacy. The network pharmacy will bill the plan for our share of the cost of your covered prescription drug. Depending on your prescription benefit, you may need to pay the pharmacy cost-share. If you do not have your plan ID card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information. If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. You can then ask us to pay you back for our share. If you cannot pay for the drug, contact Member Services right away.
To learn how to ask us to pay you back download our Member Reimbursement Form or contact Virginia Premier Member Services at 1-877-739-1370 (TTY: 711).
By law, the categories of drugs listed below are not covered by Medicare Part D plans, including Virginia Premier:
Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale.
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
For more information or details regarding a specific drug, see our downloadable Prior Authorization document found on our Plan Document Page.
For more information or details regarding a specific Part D drug, see our downloadable Step Therapy document found on our Plan Document Page.
You can find out if your drug as additional requirements or limits by using our Drug Search or downloading your plan's formulary.
You can ask Virginia Premier to make an exception to these restrictions or limits, also known as a Coverage Determination. You can find more information about coverage determinations on the Complaints, Grievances and Appeals page, and in your plan's Evidence of Coverage.
Over-the-counter (OTC) drugs are medicines that you can buy without a prescription. They are used for the treatment of minor health problems. OTC drugs are safe and effective when you follow the directions on the label and talk to your physician. The products covered in this benefit are for member use only, not for use by others (friends, family, etc.).
As part of your enrollment in Virginia Premier, you will have a credit to spend every quarter. You can only order once per quarter. Unspent money from one quarter does not carry over to any of the following quarters. If you order over the quarterly amount, the initial items ordered that totaled the quarterly amount will be shipped but the remaining items ordered will not be shipped.
|Quarter||Months||Amount Available to Spend on OTC|
|Advantage Elite (HMO SNP)||Advantage Gold (HMO)||Advantage Platinum (HMO)|
|1||January – March||$75||$35||$50|
|2||April – June||$75||$35||$50|
|3||July – September||$75||$35||$50|
|4||October – December||$75||$35||$50|
The items that you can order are generic OTC products which offer the same FDA-approved, safe and effective ingredients as brand name medications at lower costs. You can find a list of available items and the cost of each item on the order form . Examples of OTC drugs and other health and wellness items available through the program are:
How do I place my order?
Virginia Premier has partnered with OTC Health Solutions to offer you convenient access to many generic OTC products. There are 4 easy ways to order:
You should expect to receive your package within 10-15 days from the date you place your order. For questions about orders or benefits, contact OTC Health Solutions toll free at 1-888-628-2770 (TTY: 711). You can call Monday through Friday, 9:00 am to 7:00 pm
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 medicines. The MTM Program is aimed in helping 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 or do not want to take part in the program, please call Envision Pharmaceutical MTM Department at 1-866-342-2183 (TTY: 711), Monday through Friday from 9:00am to 5:00pm.
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:
If you qualify for the program, we will mail you a cover letter and a personal medication record (PMR), then a pharmacist will follow up by calling you. 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 you use 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 your 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:
Each enrolled MTM member will receive:
Virginia Premier's 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.
As a new or continuing member in our plan, you may be taking drugs that are not in our formulary (drug list). Or, you may be taking a drug that is in our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. Learn more about our Transition Policy in your plan's Evidence of Coverage.