Coverage Determinations

You can ask MVP to cover a drug that is not listed on the Formulary, or to remove additional requirements or limits on a drug's coverage. This is called a coverage determination. All requests should include a statement from your prescriber or doctor supporting your request.

Coverage Determination forms
Redetermination form

 

• Formulary Exceptions

  There are several types of exceptions that you can ask us to make.
  
  • You can ask us to cover a drug that is not listed on the Formulary. Please note that MVP cannot approve a Formulary Exception for medications that Medicare does not cover, such as cyanocobalamin injection (Vitamin B-12 injection).
  
  • You can ask us to cover a Formulary drug for a lower cost. For example, if your drug is listed in our Tier 4 Non-Preferred Drugs, you can ask us to cover it at the cost-sharing amount that applies to drugs on the Preferred Brand Name Drugs Tier 3 instead. This would lower the amount you must pay for your drug. You may not ask us to cover a Tier 5 Specialty Drug at a lower cost sharing level.
  
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, MVP Health Care limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
  
  
  

• Approval Criteria

  Generally, we will only approve your request if the alternative drugs included on the Formulary, lower cost drugs, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
  

• Decision Timing

  We must make our decision within 72 hours of getting your prescriber's supporting statement. You can request an expedited (fast) decision if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
  
  

• Appeals

  If MVP does not approve your request, you can appeal our decision and ask for a redetermination.
  
  Grievance and Appeals Information

• Transition Supply

  If a drug you take is not listed on the Formulary or includes extra rules or restrictions, you may be able to get a temporary supply of your prescription. This gives you time to work with your doctor to decide the right course of action for you.
  
  To be eligible for a temporary supply:
  
  • The drug you have been taking is no longer on the Formulary, or
  
  • The drug you have been taking is now restricted in some way.
  
  Members who were in the plan last year and do not live in a long-term care facility:
  
  • We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
  
  Members who are new to the plan and do not live in a long-term care facility:
  
  • We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
  
  Members who are new to the plan and live in a long-term care facility:
  
  • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
  
  Members who have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away:
  
  • We will cover one 31-day supply, or less if your prescription is written for fewer days. This may be in addition to the above long-term care transition supply.
  
  Transition Supply Policy.

 

Note: Certain drugs are excluded by Medicare and cannot be covered by MVP per government regulations, including vitamins, over-the-counter products, cosmetic agents, weight loss/weight gain medications, erectile dysfunction medications, DESI drugs, and unapproved drugs.

 

Last updated: October 1, 2018

Important Information

 

MVP Health Plan, Inc. is an HMO-POS/PPO/MSA organization with a Medicare contract. Enrollment in MVP Health Plan depends on contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system. Out-of-network/non-contracted providers are under no obligation to treat MVP Health Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.