Questions?

Call our Pharmacy Customer Service line, 24 hours a day, 7 days a week.

Call: 1-855-408-0010
Fax: 1-866-250-5178

For questions about MTMP, call the MTMP Hotline directly: 866-342-2183

Pharmacy Benefits

Virginia Premier CompleteCare (Medicare-Medicaid Plan), a Commonwealth Coordinated Care Plan, administers prescription drug services through EnvisionRxOptions, our pharmacy benefit manager (www.EnvisionRx.com). All prescriptions must be filled at a participating pharmacy, unless a medical or FEMA declared emergency or an out-of-area situation exists. For pharmacy and prescription related questions, please contact EnvisionRxOptions at 1-855-408-0010.

Forms & Documents

All of our forms can be found in our Provider Forms & Documents Library.


List of Covered Drugs - Formulary

You can easily search the Virginia Premier CompleteCare formulary by simply typing in the name of the medication and click ‘search.’ Coverage and/or clinical limitations will be noted next to the drug name.

Click to view full formulary

Prior Authorization (for prescription drug coverage) - PA

Certain drugs require prior approval before members can get them as a covered benefit. Prescribers can submit Prior Authorization documentation to EnvisionRxOptions for coverage determination. The prior authorization program is based on current medical findings, manufacturer labeling information, and Food and Drug Administration guidelines. Providers should use generic drugs whenever possible when prescribing medication for our members. The doctor or other network provider should contact the EnvisionRxOptions Provider Service line at 1-855-408-0010 for questions regarding drug products that require authorization, fax requests to 1-866-250-5178 or use our online PA tool to submit prior authorizations to Envision through their online portal below or to open in a new browser window here. This form can be filled out by a member, a member’s appointed representative or the prescribing doctor/provider. If the window doesn’t open right away, check for a Pop-up blocker that is stopping it or hold the “ctrl” key while you click the link.

NOTE: Virginia Premier CompleteCare (Medicare and Medicaid Managed Program) members will need to add ‘*VPHPPARTD’ to the end of the member ID number when using the Envision PromptPA tool.

For example: Medicare/Medicaid members: 1234567*VPHPPARTD
  • Prior Authorization List.
  • Part B vs. Part D: This drug may be covered under either under Part D prescription drug benefits or as a Part B drug under medical benefits, as determined by Medicare.
Note: Virginia Premier CompleteCare recommends that generic drugs which are indicated in the formulary as bio-equivalent and therapeutically equivalent be prescribed. The final decision regarding medications prescribed to an individual member is left to the physician’s professional judgment.

Step Therapy - ST

To help make the use of prescription drugs safer and more affordable, Virginia Premier CompleteCare uses a Step Therapy program. A Step Therapy program is the process where certain prescription drugs must be tried before the originally prescribed medication will be covered. The doctor can request an exception if it’s medically necessary to use the originally prescribed medication.

Quantity Limits - QL

Quantity limits restrict the frequency, amount, or dosage of medication that can be obtained each time a prescription is filled (most often set on a monthly basis).

How to contact our Precertification Unit

You can contact our Pre-certification Unit as follows:

EnvisionRxOptionsRxOptions
Attn: Coverage Determinations Dept.
2181 East Aurora Road
Twinsburg, OH 44087
Fax Number: 1-866-250-5178
Toll-Free Number: 1-855-408-0010
TTY Number: 711

Hours of Operation: 24 hours a day, 7 days a week

Once we receive the physician’s statement, we must notify the member of our decision no later than 24 hours for an expedited request, or no later than 72 hours for a standard request. The request will be expedited if we determine, or the doctor informs us that the member’s life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard request.

What if your request is denied?

If the request is denied, the member has the right to appeal by asking for a review of our decision. The doctor or the member must request this appeal within 60 calendar days from the date of our decision. If you want to file an expedited appeal, you can call or fax us. If you want to file a standard appeal, you must write or fax us.

For an Expedited Appeal, phone or fax:
Grievances and Appeals Phone Number: 1-800-727-7536
Grievances and Appeals Fax Number: 804-649-9647

For a Standard Appeal, write or fax:

Virginia Premier Health Plan, Inc.
Attn: Grievance & Appeals
PO Box 5244
Richmond, VA 23220

Grievances and Appeals Fax Number: 804-649-9647

Specialty Drugs

Specialty 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. People who take specialty drugs require customized clinical monitoring and support to reduce their health risks and potentially serious side effects.

All pre-authorizations for specialty drugs are administered by EnvisionRxOptions at 1-855 408-0010.

Specialty Pharmacy services are provided by our preferred specialty pharmacy vendor, Orchard Specialty Pharmacy.

Network Specialty Pharmacy

Virginia Premier CompleteCare has designated Orchard Specialty Pharmacy to provide specialty drugs to our members who need them, at the most reasonable cost possible:

Orchard Specialty Pharmacy – Provider Line: 1-877-437-9013, Fax: 877-309-0687

Once prior authorization is obtained, providers will be informed about the available options on the specialty drugs. All specialty pharmacy order forms can be located at .

CompleteCare Medicare Transition of Coverage Process for Part D Drugs

The Centers for Medicare and Medicaid Services (CMS) require Part D Plan Sponsors, like Virginia Premier CompleteCare, to have a transition of coverage (TOC) process. Medicare Part D transition period is the first 90 days of a member’s enrollment. Members who are taking Part D drugs that are not on the plan’s formulary or that are subject to utilization management requirements can get a transition supply of their drug in certain circumstances. This gives members the opportunity to work with their doctor to complete a successful transition and avoid disruption in their treatment.

If you have questions about the process or would like more details, please contact EnvisionRxOptionsRxOptions at 1- 855-408-0010 (TTY/TDD: 711), 24 hours a day, 7 days a week.

Medication Therapy Management (MTM)

Virginia Premier CompleteCare has chosen EnvisionRxOptions to administer our Medication Therapy Management (MTM) Program. We offer this program to patients who meet certain criteria established by the Centers for Medicare and Medicaid (CMS), with recommendations and guidance from EnvisionRxOptions Pharmacy and Therapeutics Committee. These criteria include, but are not limited to: patients who suffer with multiple chronic diseases, receiving multiple medications, and are likely to incur costs greater or equal to $3,138 annually. This program provides patients and their physicians with information regarding medication therapy and disease management.

The goal of the MTM program is to help patients improve therapeutic outcomes for certain disease states by improving medication use and reducing the number of possible adverse drug events. Patients are automatically enrolled in the program unless they choose not to participate. They receive quarterly educational information from EnvisionRxOptions and have the ability to set personal goals with the program. Additional educational information is available at: http://www.envisionrx.com/healthdrug.aspx.

As part of our service, we review prescription claims and notify the physicians of possible drug therapy problems. The benefits of the MTM program include more effective use of prescription medications and better management of health conditions. Our recommendations may be limited to information available through the patient’s prescription history with EnvisionRxOptions. We may not have access to all relevant clinical information such as medical history and lab data. The success of this MTM Program is based on collaboration between the physician, patient and other health professionals.

Over-the-Counter Medications - Medicaid Wrap Drugs or ADD

There are specific drug classes that, by law, are not covered under the Medicare Part D program but are covered by Medicaid. Virginia Premier CompleteCare covers these medications in accordance with existing Medicaid policy. The drug classes that Medicare does not cover, but that are covered by Virginia Medicaid (known as Medicaid Wrap Drugs or ADD-Additional Demonstration Drugs) for Medicare Medicaid members include:
  1. Select medications for weight loss (service/prior authorization required);
  2. Select legend and non-legend medications for symptomatic relief of cough and colds;
  3. Select prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations);
  4. Select FDA approved over-the-counter medications (prescriptions are required);
Virginia Premier CompleteCare shall also cover compounded prescription drug products for Part D members that contain: (1) all Part D drug product components; (2) some Part D drug product components; or (3) drug components covered by Virginia Medicaid (i.e., drugs listed above, i-iv). A list of Medicaid Wrap Drugs.

How do I obtain diabetic supplies for my patients?

Q: How do I obtain diabetic supplies for my patients?

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

Our preferred vendors for meters (Glucometers) are Abbott and Bayer. Strips, lancets, and control solutions are covered under the pharmacy benefit at your local pharmacy. Your patient can receive a free meter of choice from ABBOTT by calling 1-866-224-8892 or from BAYER by calling 1-800-401-8440. Insulin pumps are subject to Medical Necessity and available through DME (Durable Medical Equipment) vendors.

Our goal is to provide your patients with the best care. If you have any questions about your plan coverage, please contact Virginia Premier member services at 1-800-727-7536.

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
  • NDC
  • 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 frequent than every 7 days.