Pharmacy Part D Services

Virginia Premier Elite (HMO SNP) administers Prescription Part D services through Envision Pharmaceutical Services, our pharmacy benefit manager (www.EnvisionRx.com).

All prescriptions must be filled at a network pharmacy, unless a medical or FEMA declared emergency or an out-of-area situation exists. To locate a network pharmacy visit our Provider & Pharmacy Directory page.

For pharmacy and prescription related questions, please contact Envision Pharmaceutical Services at 1-855-408-0010 (TTY users call 711), 24 hours a day, 7 days a week.

Formulary

The plan will pay for medications on the formulary but some drugs may require a coverage determination before we will pay for it. Visit the Provider Formulary Page for more information.

For information about Part D Vaccines and how to receive reimbursement, visit our Medicare Part D Vaccine and Administration page.

Network Pharmacy

In most cases, our plan will pay for prescriptions only if they are filled at the plan’s network pharmacies. To find a network pharmacy, visit our Provider Locator. Our network includes:

  • Retail Pharmacies
  • Mail Order Pharmacies
  • Long-Term Care Pharmacies
  • Home Infusion Pharmacies
  • Specialty Pharmacies

Mail Order Pharmacy

For certain kind of drugs, the member can use the plan’s network mail-order services. Our plan’s mail-order service allows a member to order a 90-day supply with the same co-pay as a one-month supply. The preferred mail order pharmacies include:

Envision Pharmacies
7835 Freedom Avenue NW
North Canton, OH 44720
Phone: 1-866-909-5170
Curant Health Georgia LLC
200 Technology Court SE,
Suite B
Smyrna, GA 30082
Phone: 1-866-437-8040

Note: A 90-day supply may also be available at our retail providers.

Specialty Pharmacy Benefits

Specialty drugs are high-cost injectable, infused, oral, or inhaled medications that are typically prescribed to treat complex 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 risk and potentially serious side effects.

Most Specialty drugs require prior authorization whether self-administered, administered in the office or by a home health service. Authorizations are based on medical necessity, which is determined by the drug policy, evidence-based medicine, regulations, contracts and medical judgment.

To find a network Specialty Pharmacy, you can look in the Pharmacy Directory on our website.

The preferred specialty pharmacy is:
Envision Pharmacies
7835 Freedom Avenue NW
North Canton, OH 44720
Phone: 1-866-909-5170
Monday – Friday: 8am – 10pm
Saturday: 8:30am – 4:30pm

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.

Diabetic Supplies

Test strips, lancets, meters, control solutions and insulin pump supplies are covered under our 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 brands for meters (Glucometers) are Abbott and Bayer. 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.

Prescription Drug Coverage Determination

If there is a restriction for a drug, it usually means that the member or the provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for the member, a coverage determination is required. Visit the Prescription Drug Coverage Determination Request page for more information.

Medication Therapy Management (MTM)

Medication Therapy Management (MTM) is a pharmacy program offered by Virginia Premier’s Part D programs. This program is available at no cost to members and intended for those who are on multiple medications. Envision Pharmaceutical Services administers our MTM Program. The goal of the program is to provide information to the members, their doctors, and their pharmacists. This information will help improve medication use and coordination of care.

Visit the Envision MTM Program webpage for more details.

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 Elite, to have a transition of benefit process. For more information about Transition Benefits and temporary fills visit the Transition Fill Web Page.