Plan Documents

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Member Handbook (Evidence of Coverage)

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

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Annual Notice of Change

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

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Summary of Benefits

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

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Sample ID Card

(PDF)
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View a sample Virginia Premier CompleteCare ID card.

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Multi-Language Insert

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View the Multi-Language Insert.

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Provider/Pharmacy Directory

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

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List of Covered Drugs (Formulary)

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

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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.

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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

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Grievance and Appeals Form

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

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Medicare Request for Drug Determination Form

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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.

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Request for Drug Coverage Re-determination Form

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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).

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Member Reimbursement Form for Part D Drugs

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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 pageComplaints and Grievances for more information.