A formulary is a list of drugs that a plan covers. The Virginia Premier Gold formulary is designed to include all drug categories and provide doctors with prescribing options. Through an arrangement with PerformRx, a national pharmacy benefits administrator, Virginia Premier Gold provides Medicare Part D prescription benefit management services to our members, which includes a formulary.
Drug Tiering Information
The first column of the Printable Formulary chart lists the drug name. Brand-name drugs are capitalized (e.g., ALLEGRA and generic drugs are listed in lower-case italics (e.g., fexofenadine)).
The following table explains the Drug Type and Co-payment amount / Coinsurance percentage associated with each Drug Tier Number.
Drug Tier |
Drug Type |
Co-payment Retail |
Mail Order |
| Tier 1 |
Generic |
$0 / $1.05 / $2.25 |
$0 / $1.05 / $2.25 |
| Tier 2 |
Preferred Brand |
$0 / $3.10 / $5.60 |
$0 / $3.10 / $5.60 |
| Tier 3 |
Non-Preferred Brand |
$0 / $3.10 / $5.60 |
$0 / $3.10 / $5.60 |
| Tier 4 |
Specialty |
$0 / $3.10 / $5.60 |
$0 / $3.10 / $5.60 |
The formulary has been reviewed and approved by the Centers for Medicare and Medicaid Services (CMS), the agency that administers the Medicare Program. Formulary medications are FDA-approved and have been chosen for their reported medical effectiveness and value. Formularies are reviewed periodically to add new drugs and to remove brand-name drugs when a generic equivalent becomes available.
Those medications not on our formulary, as well as some formulary medications, will require prior authorization. For more information on how your doctor can request prior authorization please see our Prior Authorization Process.
For information on how you can file an appeal or grievance if a prior authorization request is denied, please contact the Virginia Premier Gold Appeals & Grievances Department.
In order to receive benefits through Virginia Premier Gold, prescriptions must be filled at a Virginia Premier Gold network pharmacy.
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