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Pharmacy Benefits

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).

2018 Pharmacy Benefits

More details on your Pharmacy Benefits can be found in your plan's Evidence of Coverage document.

Prescriptions

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:

  • You must have a provider (a doctor, dentist or other prescriber) write you a prescription.
  • Your prescriber must either accept Medicare or file documentation with CMS showing that he or she is qualified to write prescriptions, or your Part D claim will be denied. You should ask your prescribers the next time you call or visit if they meet this condition. If not, please be aware it takes time to process the necessary paperwork in order to get qualified.
  • You generally must use a network pharmacy to fill your prescription. Use our provider search tool to find a network pharmacy.
  • Your drug must be on the plan's Formulary.
  • Your 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.

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:

  • 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
    • to 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)

*Please note:Virginia Premier does offer select over-the-counter drugs through your supplemental benefits.

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.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization: Virginia Premier requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Virginia Premier before you fill your prescriptions. If you don't get approval, Virginia Premier may not cover the drug.

    For more information or details regarding a specific drug, see our downloadable Prior Authorization document found on our Plan Document Page.

  • Quantity Limits: For certain drugs, Virginia Premier limits the amount of the drug that Virginia Premier will cover. For example, Virginia Premier provides 60 capsules per 30 days per prescription for Vraylar Capsules 3mg. This may be in addition to a standard one-month or three-month supply.
  • Step Therapy: In some cases, Virginia Premier requires you to first try certain drugs to treat your 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, Virginia Premier will then cover Drug B.

    For more information or details regarding a specific Part D drug, see our downloadable Step Therapy document found on our Plan Document Page.

  • Part B or D Determination: In some cases, the prescription drug may be covered under Medicare Part B or Part D. Virginia Premier requires additional information to explain the use and setting of the drug to make the determination.

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.

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 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.

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
    • Diabetes
    • Dyslipidemia
    • Hypertension
    • 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 calendar year and is re-evaluated annually.

How does the MTM program work?

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:

  • Once every 3 months, you will be contacted via mail or phone for a review.
  • Your 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 be received?

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.

Here is a sample Personal Medication List

Transition Fill Policy

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.

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2019 Pharmacy Benefits

More details on your Pharmacy Benefits can be found in your plan's Evidence of Coverage document.

Prescriptions

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:

  • You must have a provider (a doctor, dentist or other prescriber) write you a prescription.
  • Your prescriber must either accept Medicare or file documentation with CMS showing that he or she is qualified to write prescriptions, or your Part D claim will be denied. You should ask your prescribers the next time you call or visit if they meet this condition. If not, please be aware it takes time to process the necessary paperwork in order to get qualified.
  • You generally must use a network pharmacy to fill your prescription. Use our provider search tool to find a network pharmacy.
  • Your drug must be on the plan's Formulary. Search your drugs using our online drug search
  • Your 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.

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:

  • 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
    • to 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)

*Please note:Virginia Premier does offer select over-the-counter drugs through your supplemental benefits.

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.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization: Virginia Premier requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Virginia Premier before you fill your prescriptions. If you don't get approval, Virginia Premier may not cover the drug.

    For more information or details regarding a specific drug, see our downloadable Prior Authorization document found on our Plan Document Page.

  • Quantity Limits: For certain drugs, Virginia Premier limits the amount of the drug that Virginia Premier will cover. For example, Virginia Premier provides 60 capsules per 30 days per prescription for Vraylar Capsules 3mg. This may be in addition to a standard one-month or three-month supply.
  • Step Therapy: In some cases, Virginia Premier requires you to first try certain drugs to treat your 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, Virginia Premier will then cover Drug B.

    For more information or details regarding a specific Part D drug, see our downloadable Step Therapy document found on our Plan Document Page.

  • Part B or D Determination: In some cases, the prescription drug may be covered under Medicare Part B or Part D. Virginia Premier requires additional information to explain the use and setting of the drug to make the determination.

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.

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 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.

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
    • Diabetes
    • Dyslipidemia
    • Hypertension
    • Respiratory Disease – Chronic
    • HIV-AIDS
  • Taking eight or more daily Part D medications.
  • Spending $4,044 or more per year on Part D covered medications. Membership is per calendar year and is re-evaluated annually.

How does the MTM program work?

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:

  • Once every 3 months, you will be contacted via mail or phone for a review.
  • Your 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 be received?

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.

Here is a sample Personal Medication List

Transition Fill Policy

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.

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