Medicare Coverage Determinations

Exceptions to Our Policies for Prescription Drug Coverage

MVP has policies to ensure our members use prescription drugs in the most effective way and to help us control costs for our drug plans. You may ask us for a coverage determination, or to make an exception, if:

We don’t cover a drug you take
You need us to cover a drug at a lower cost than normal
You need us to remove an additional requirement or limit on a drug’s coverage

How Do I Request a Coverage Determination?

To request a coverage determination, please complete our coverage determination form. You can use our fillable web form, or you can print and complete a PDF version. Always include a statement from your prescriber or doctor that supports your request.

In most cases, we’ll only approve your request if the following are true:

No alternative drugs on the Formulary would be as effective in treating your condition
No lower-cost drugs would be as effective in treating your condition
The requirements or limits we have in place for a drug would cause you to have adverse medical effects
The requirements or limits we have in place for a drug would limit its effectiveness in treating your condition

What Coverage Determinations Can I Request?

Some examples of coverage determinations you can request include:

Coverage for a drug we don’t list on our Formulary. Unfortunately, by regulation, MVP can’t approve a formulary exception for drugs Medicare doesn’t cover.
Coverage for a drug we list on our Formulary but at a lower cost than we usually cover. Please note: We can’t lower the cost-sharing level of a Tier 5 Specialty drug.
Coverage restrictions or limits on your drug. For example, if we usually limit the amount of a drug we will cover, you can ask us to waive the limit to cover a greater amount.

How Quickly Can I Expect a Decision on My Coverage Determination?

We must decide on your request for a coverage determination within 72 hours of receiving a supporting statement from your prescriber or doctor.

You can request an expedited (faster) decision if you or your doctor believes waiting up to 72 hours for a decision could seriously harm your health. If we grant your request to expedite the decision, we must give you a decision no later than 24 hours after we receive a supporting statement from your prescriber or doctor.

How Can I Appeal a Denial of My Coverage Determination?

If we don’t approve your request for a coverage determination, you can ask for a redetermination using our redetermination request form (PDF). Learn more about grievances and appeals (PDF).

Can I Get a Transition Supply of My Medication?

If we don’t list a prescription drug you take in our Formulary, or if that drug includes extra rules or restrictions for its use, you may be able to get a temporary (transition) supply of your prescription. This gives you time for you and your doctor to decide the best course of action.

To qualify for a transition supply, your prescription drug must no longer be on our Formulary, or the drug must now be restricted in some way.

Please note: Medicare excludes certain drugs from coverage. Per government regulations, we can’t cover these drugs. These drugs include:

Cosmetic agents
Drugs on the U.S. Food & Drug Administration’s Drug Efficacy Study Implementation (DESI) list
Erectile dysfunction medications
Over-the-counter products
Unapproved drugs
Vitamins
Weight-loss/weight-gain medications

For more details, please view our Transition Supply Policy (PDF). If you need a transition supply of your medication, please choose the scenario below that matches your situation.

I Had an MVP Medicare Plan Last Year, and I Don’t Live in a Long-Term Care Facility

We’ll cover a transition supply of your drug one time only during the first 90 days of the calendar year. This coverage will be for a 30-day supply at most. If your prescription is written for fewer days, the supply will be for that amount of time. You must fill your prescription at an in-network pharmacy.
I’m New to an MVP Medicare Plan, and I Don’t Live in a Long-Term Care Facility

We’ll cover a transition supply of your drug one time only during the first 90 days of your membership in your Medicare plan. This coverage will be for a 30-day supply at most. If your prescription is written for fewer days, the supply will be for that amount of time. You must fill your prescription at an in-network pharmacy.
I’m New to an MVP Medicare Plan, and I Live in a Long-Term Care Facility

We’ll cover a transition supply of your drug one time only during the first 90 days of your membership in your Medicare plan. The coverage will be for a maximum 31-day supply. If your prescription is written for fewer days, the supply will be for that amount of time. If needed, we will cover additional refills during your first 90 days in the plan up to a maximum of a 31-day supply.
I’ve Been in an MVP Medicare Plan for More Than 90 Days, I Live in a Long-Term Care Facility, and I Need a Transition Supply Right Away

We’ll cover one 31-day supply of your drug. If your prescription is written for fewer days, the supply will be for that amount of time. This may be in addition to the above long-term care transition supply.

MVP Health Plan, Inc. is an HMO-POS/PPO/HMO D-SNP organization with a Medicare contract and a contract with the New York State Medicaid program. Enrollment in MVP Health Plan depends on contract renewal. MVP Health Plan, Inc. has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 12/31/2024 based on review of MVP Health Plan’s Model of Care. Health benefit plans are issued by MVP Health Plan, Inc., an operating subsidiary of MVP Health Care, Inc. Not all plans available in all states and counties. 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. For accommodations of persons with special needs at meetings, call 1-800-324-3899 (TTY 711).

Other physicians/providers are available in the MVP Health Care network. Gia virtual care services are available at no member cost-share for medical plans, including qualified high-deductible health plans (QHDHPs). Exceptions may apply for self-funded plans. In-person visits and referrals are subject to cost-share per plan. Members enrolled in a Medicare Rx plan without additional MVP medical coverage do not have access to MVP virtual care services through Gia. SilverSneakers is a registered trademark of Tivity Health, Inc. SilverSneakers On-Demand is a trademark of Tivity Health, Inc. ©2024 Tivity Health, Inc. All rights reserved. GetSetUp is a third-party provider and is not owned or operated by Tivity Health, Inc. (“Tivity”) or its affiliates. Users must have internet service to access online services. Internet service charges are responsibility of user.

TruHearing® and (RE)TM are trademarks of TruHearing, Inc. All other trademarks, product names, and company names are the property of their respective owners. Retail pricing based on prices for comparable aids. Follow-up provider visits included for one year following hearing aid purchase. Free battery offer is not applicable to the purchase of rechargeable hearing aid models. Three-year warranty includes repairs and one-time loss and damage replacement. Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact a TruHearing hearing consultant.

©2024 NationsBenefits, LLC. and NationsOTC, LLC. NationsOTC is a registered trademark of NationsOTC, LLC. All other marks are the property of their respective owners. Mom’s Meals® is a registered trademark of PurFoods, Inc.

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Last Updated: 10/1/2024

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