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 plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Examples of pharmacy management programs are described below:

1. Prior Authorization: MVP requires that you get prior authorization for certain drugs. This means that your provider must ask for prior authorization from the plan. You will need to get approval from MVP before you can fill your prescription. If prior approval is not obtained, the drug will not be covered.
   
   
   • Click here to see if the drug you take requires prior authorization.
   • Click here to obtain a prior authorization form.
     
     
2. Formulary Exceptions: Some MVP plans (ie: MVP Option Child and Healthy New York) have a two-tier benefit where only generic and formulary brand drugs are covered. If a non-formulary, tier 3 drug is medically necessary, your provider must submit a request for the non-formulary drug.
   
   
• Click here to obtain a prior authorization form.
  
  
3. Quantity Limits: For certain drugs, MVP limits the amount of the drug that is covered per prescription or for a defined period of time. For example, MVP will provide up to 30 capsules per month for Nexium.  If your prescription is for a quantity greater than what MVP allows, prior authorization is required. Some examples of drug classed where quantity limits apply include but are not limited to sleep agents, headache medications, chemotherapy anti-emetics, proton pump inhibitors (ulcer medication) and erectile dysfunction drugs.
   
   
• Click here to see if the drug you take is subject to quantity limits.
• Click here to obtain a prior authorization form.
  
  
4. Step Therapy: In some cases, MVP 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 with prior authorization.
   
   
• Click here to see if the drug you take requires step therapy.
• Click here to obtain a prior authorization form.
  
  
5. Generic Substitution/MAC Program: When there is a generic version of a brand-name drug available, our network pharmacies may be required to give you the generic version (based on the laws of the state where they are located), unless your doctor indicates on the prescription that you must take the brand-name drug. While the use of bioequivalent generic drugs is encouraged to help you stretch your pharmacy dollar further, you are not required to receive the generic drug. If your physician writes “DAW”, you will receive the brand name drug, but may be responsible for the difference in cost between the generic and the brand name drug plus your copayment. This is referred to as the Generic MAC program.