On this page, you’ll find the information you may need to get the most out of Virginia Premier CompleteCare (Medicare-Medicaid Plan), a Commonwealth Coordinated Care plan. Plan documents, forms and details about your benefits as a CompleteCare member are all right here.

Plan Documents - 2016

Provider/Pharmacy Directory

View a full list of providers and pharmacies in the Virginia Premier CompleteCare network. Download (PDF) Find a doctor, specialist, hospital or pharmacy near you. Search here.

Member Handbook (Evidence of Coverage)

(PDF) This document provides you comprehensive information about your coverage in Virginia Premier CompleteCare.

Annual Notice of Change

(PDF) This document provides you a list of changes about your coverage compared to last year.

List of Covered Drugs (Formulary)

Download the full list of covered drugs (Formulary) by Virginia Premier CompleteCare.

Summary of Benefits

(PDF) This document gives an overview of Virginia Premier CompleteCare benefits.

Multi-Language Insert

View the Multi-Language Insert.

Member ID Cards

(PDF) See what the 2016 member ID card looks like.

Plan Documents - 2017

Provider/Pharmacy Directory

View a full list of providers and pharmacies in the Virginia Premier CompleteCare network. Download (PDF) Find a doctor, specialist, hospital or pharmacy near you. Search here.

Member Handbook (Evidence of Coverage)

(PDF) This document provides you comprehensive information about your coverage in Virginia Premier CompleteCare.

Annual Notice of Change

(PDF) This document provides you a list of changes about your coverage compared to last year.

List of Covered Drugs (Formulary)

Download the full list of covered drugs (Formulary) by Virginia Premier CompleteCare.

Summary of Benefits

(PDF) This document gives an overview of Virginia Premier CompleteCare benefits.

Multi-Language Insert

View the Multi-Language Insert.

Member ID Cards

(PDF) See what the 2017 member ID card looks like.

Prior Authorization List

Prior Authorization List (PDF)

Prior Authorization List for OTC/Supplemental Drug List

Prior Authorization List (PDF)

Step Therapy List

Step Therapy List (PDF)

Forms


Appointment of Representative Form

This form is used to appoint an individual to act as your representative. You can name another person to ask for a coverage decision or make an appeal. If you want a friend, relative, lawyer or another person to be your representative, this form will give the person permission to act for you. You must give us a copy of the signed form.

Request ID Card Form- Coming soon!

Use this form to request a new Virginia Premier CompleteCare ID card. To submit this form to us, please download the form, fill in the information and mail it to: CompleteCare Member Services PO Box 4466 Richmond, VA 23220

Grievance and Appeals Form

Use this form to file a complaint or appeal with Virginia Premier CompleteCare.  See our Grievances and Appeals page for more information.

Medicare Request for Drug Determination Form

Use this form to file a coverage determination request for a Part D drug with Virginia Premier CompleteCare. See our Grievances and Appeals page for more information.

Request for Drug Coverage Re-determination Form

If we deny your request for coverage of (or payment for) a prescription drug, and you don’t agree with our decision, use this form to file a coverage re-determination (appeal).

Member Reimbursement Form for Part D Drugs

If you paid the full cost of a prescription from one of our Network Pharmacies, use this form to ask us to pay you back for our share.  See our Pharmacy page for more information.

Substance Use Disorder Member Release of Confidential Information Consent Form

 

Have Questions? Let’s talk.

Call us at 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice). The call is free.

Additional Information

Virginia Premier CompleteCare is a health plan that contracts with both Medicare and the Virginia Department of Medical Assistance Services to provide benefits of both programs to enrollees.

Limitations, copays, and restrictions may apply. For more information, call Virginia Premier CompleteCare Member Services or read the Virginia Premier CompleteCare Member Handbook.

Benefits, List of Covered Drugs, and pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year. You can get this information for free in other languages. Call 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice). The call is free.

You can ask for this information in other formats, such as Braille or large print. Call 1-855-338-6467, 8:00 a.m. to 8:00 p.m., Monday through Friday. For TTY/TDD services, please call 1-800-828-1120 (Text), 1-800-828-1140 (Voice).

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