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MVP Medicare Customer Care Center
Monday - Friday
8 am - 8 pm (EST)
From Oct. 1 - Feb 14, call seven days a week, 8 am to 8 pm
MVP Medicare Product Advisors
Monday - Friday, 8 am - 8 pm (EST)
220 Alexander St.
Rochester, NY 14607
24/7 Nurse Advice Line
Request a Coverage Determination or Formulary Exception
Phone: 855 853-4852
Click on a link below to get the answers to our members' most frequently asked questions.
Drug Coverage Questions:
- What does "tier" mean?
- What Tier level is my drug in?
- What if my drug isn't listed in the Formulary?
- Can you explain my Part D Explanation of Benefits (EOB) to me?
Vaccine Coverage Questions
- How can I avoid overpaying for my Part D vaccine?
- I had to pay up front for the cost of my Shingles vaccine and the administration. How do I get reimbursed now?
- How are vaccines covered?
Out of Area Coverage Questions:
- I'm going on a cruise. If I need a prescription filled on the boat, will it be covered?
- I want to go to Canada to get my prescription filled. Will it be covered?
- I'm going on vacation within the US. Are my prescriptions covered?
Pharmacy Management Questions:
- What is Pharmacy Management?
- What drugs need Prior Authorization?
- What drugs have Quantity Limitations?
- What drugs have STEP Therapy requirements?
Mail Order Questions:
- What prescriptions are available through the mail?
Extra Help and Other Plan Questions:
- Am I eligible for "extra help" for Part D prescription drug coverage?
- Can I have New York State EPIC and Part D Prescription drug coverage?
- Do I qualify for New York State's EPIC drug program?
- How does VA coverage work with Part D?
Prescription drugs come in a wide range of prices, even for those that are used to treat the same condition. MVP divides prescription drugs into five tiers. Learn more about 2017 Tiered Prescription Drug Benefits.
Tier 1-Preferred Generic Drugs
Tier 1 includes select drugs for diabetes, blood pressure control, glaucoma, gout, bone health, heartburn and ulcers, mental health conditions, pain management, cholesterol control, and thyroid conditions. The drugs in Tier 1 are provided at little or no cost to you.
Tier 2-Generic Drugs
Tier 2 includes generic drugs (Note: Not all generic drugs will be Tier 2 drugs). Generic drugs have the same active ingredients, strength, and effectiveness as the brand-name versions, but at a much lower cost. For low out-of-pocket costs, you should always think about using Tier 2 Generics if you and your doctor decide they are right for you.
Tier 3-Preferred Brand Name Drugs
Tier 3 includes preferred brand drugs that have the lowest cost sharing for brand name drugs. If you and your doctor decide that a brand name drug is right for you, try using a Tier 3 brand name drug to save you money.
Tier 4-Non-preferred Drugs
Tier 4 includes brand name and generic drugs. In addition, Part D drugs excluded from our Formulary must go through an exception process in order for MVP to cover them. If they are approved, they may be covered in Tier 4.
Tier 5-Specialty Drugs
Tier 5 includes all drugs (brand name and generic) that cost $670 or more for a 30-day supply. Most drugs in this tier are restricted to a 30-day supply at retail, and are excluded from the mail order program.
Tier 6 includes the most common Part D vaccines: the shingles vaccine (Zostavax), tetanus vaccines, and combination tetanus / diphtheria / pertussis vaccines (such as Tenivac, Adacel and Boostrix). The vaccines in Tier 6 are provided at no cost to you.
Member co-payments may be different than what is listed in the Formulary for a number of reasons such as:
- Coverage Gap or Donut Hole- during the Coverage Gap phase of your Part D coverage, you will be responsible for 51% for generic drugs and 40% for CMS contracted brand drugs.
- Catastrophic Coverage- once you hit the Catastrophic Phase of your Part D coverage, your co-pays will be much less than those listed in the Formulary.
- Part B drugs- if you are taking a medication or using a supply that is considered a Part B benefit by CMS, you will be required to pay a 10% or 20% co-insurance for that supply or drug. Part B products will not count toward your total drug costs or out-of-pocket costs.
- Employer Group Rx Rider- MVP Health Care offers many different Part D plans to members who get their insurance through a former employer. These employer group plans may have different co-pays than those listed in the Formulary during the coverage gap stage of their benefit..
- State Pharmaceutical Assistance Programs- Part D members who have EPIC in New York or V-Pharm in Vermont in addition to their MVP Health Care coverage may have reduced co-pays at the pharmacy.
- Low Income Subsidy (LIS)- Part D members with LIS coverage (members who receive extra help) have co-pays that are less than those listed in the Formulary.
Certain classes of medicines are considered Part D excluded drugs as determined by Medicare. Part D excluded classes of medication include:
- Cough and Cold medications
- Over the Counter products
- Cosmetic agents
- Weight Loss medications
- Erectile Dysfunction medications
- DESI drugs
- Unapproved drugs
If you have questions about Part D excluded medications, please contact MVP's Medicare Customer Care Center at the number on the back of your member ID card.
As a new member in our plan, you may currently be taking drugs that are not on our Formulary or are on our Formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our Formulary. If there are no appropriate alternative therapies on our Formulary, you or your doctor can request a Formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30 days transition supply of the drug anytime during the first 90 days you are a member of our plan. View the full General Transition Notice.
Why did my pharmacy fill my prescription for 30 days when my doctor wrote the prescription for 90 days?
Not all pharmacies sign contracts with MVP to dispense up to a 90 day supply. Pharmacies that refuse to join the 90-day network will only be able to dispense a 30 day supply of medication. If you wish to obtain greater than a 30 day supply of medication, you should look for a pharmacy in the network that has signed our 90-day contract (most area pharmacies fall into this category), or you could consider using the CVS/caremark mail service. Certain drugs are limited to a 30-day supply per fill. These drugs are listed in the Formulary with a "DL" in the Requirements/Limits column.
Members will pay the least for Part D vaccines when vaccinated:
- At a pharmacy that is in the MVP pharmacy network.
- At a doctors office that has enrolled with TransactRX online Part D vaccine claim billing.
If members do not follow one of the above scenarios, they will pay for the entire cost of the vaccine up front. They will need to complete the Medicare Part D Prescription Claim Form and submit the form to CVS/caremark. Whenever possible, members should bring their prescription claim form to their doctors appointment for help filling it out. Members will only be reimbursed the negotiated rate minus their applicable co-paywhich could be less than they paid out of pocket.
If you dont wish to pay for Part D vaccines out of pocket and then have to submit the claim form for reimbursement, ask your local pharmacy if they can provide the vaccine for you. You can ask your doctor to bill your Part D vaccine claims through TransactRX. TransactRX is an on-line tool that doctors can use to bill Part D vaccine claims directly to CVS/caremark on your behalf. This also ensures you pay the correct co-pay for the drug at the time of your visit. If your doctor doesnt know about TransactRX, please tell them to visit www.mvphealthcare.com/providers or call MVP Provider Services at 1-800-684-9286 for information.
I had to pay up front for the cost of my Shingles vaccine and the administration. How do I get reimbursed now?
Fill out a Medicare Part D Prescription Claim form to submit to CVS/caremark. Please include a copy of your paid receipts to ensure proper and timely processing. If you need help filling out your claim form, please ask your doctor or call the MVP Health Care Customer Care Center.
Most commercially-available vaccines will be covered under your Part D pharmacy benefit. This also includes the administration fees associated with the vaccinations. Some other vaccines are covered as a Part B medical benefit, such as pneumococcal, rabies, and flu. Learn more about how vaccines are covered by MVP Health Care.
No. According to CMS guidelines, cruise ships are considered outside United State borders. Part D pharmacy benefits do not cover prescriptions filled outside the United States. Please make sure to fill your prescription prior to traveling on a cruise ship.
No. According to CMS guidelines, Part D pharmacy benefits do not cover prescriptions filled outside the United States.
Yes. Prescriptions for drugs on the MVP covered drug list (Formulary) filled in the United States are covered Part D benefits. It is important to provide out of area pharmacies with your Part D prescription benefit card to ensure claims are billed online to CVS/caremark. Make sure to bring your benefit card with you on vacation.
For certain prescription drugs, MVP Health Care has additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members.
We require you to get prior authorization for certain drugs. This means that your prescriber may ask for prior authorization from the Plan. You will need to get approval from MVP Health Care before you fill your prescription. If you don't get approval, the drug may not be covered. View the complete list of drugs that require a Prior Authorization for 2017.
For certain drugs, MVP Health Care limits the amount of the drug that is covered per prescription or for a defined period of time. For example, MVP Health Care will provide up to 30 capsules per month for Dexilant. View the complete list of drugs that have a Quantity Limit for 2017.
In some cases, MVP Health Care requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. View the complete list of drugs that have a Step Therapy requirement for 2017.
CVS/caremark is MVP Health Cares contracted Pharmacy Benefit Manager and mail order pharmacy vendor for all of our health plans. Just like MVP, the CVS/caremark Customer Care is dedicated to helping you get the medications you need. If you have questions about your pharmacy benefits, the CVS/caremark Customer Care can help explain your MVP Health Care prescription coverage.
Log In/Register to your MVP online account and select Pharmacy (CVS/caremark) to manage your mail order prescriptions and view personalized information about your pharmacy benefits.
MVP Health Care is required to send out an Explanation of Benefits (EOB) statement on a monthly basis to all members who use their Part D pharmacy benefit. Learn more about the EOB statement.
Only certain drugs are allowed through the mail order pharmacy program. (Drugs that are not available via mail will have an NM in the Requirements/Limits column of the Formulary.)
Many Part D prescription drugs can be purchased through the CVS Caremark Mail Service Pharmacy. You receive up to a 90 supply for 2 times the normal 30 day supply co-payment. This saves you 1 co-payment for each 90 day supply. However, not all medications are less expensive through the mail. For example, if you are in the Coverage Gap or Donut Hole, some medications may be less expensive at a local pharmacy. You can Log In/Register to your MVP online account and select Pharmacy (CVS/caremark) to obtain pricing for mail order prescriptions.
You need to complete an application to determine if you are eligible to receive extra help. If you think that you may qualify for the Medicare Prescription Drug Coverage (Part D) low-income subsidy, complete the application. If you need a copy, or if you need help filling out the form, visit the Social Security Administration Office near you, or call 1-800-772-1213. TTY users may call (800) 325-0778. View more "extra help" information and resources available to you.
MVP Health Care's Part D coverage and EPIC coverage can work together. You must show both cards to the pharmacy to ensure that the lowest co-payment is applied to your purchase. Also, if you have EPIC coverage, EPIC may help you pay some of your Part D monthly premium.
Contact EPIC for more details about how its prescription drug plan works together with the Medicare prescription drug plan (Part D). Call EPIC at 1-800-332-3742. TTY users may call 1-800-290-9138 or visit the New York State EPIC website.
Note: You cannot have EPIC coverage unless you are enrolled in Part D or have creditable coverage through a former employer.
Your VA prescription drug benefits are not affected by the Medicare prescription drug coverage (Part D). You may enroll in Part D if you choose. View more information on VA coverage.
Last updated: October 2016