The VIVA Medicare Plus Rx and VIVA Medicare Plus Rx Healthy Lifestyles plans both include the Medicare Part D prescription drug benefit offered under a contract with Medicare. Some important information regarding your prescription drug benefits is included below.

Please see also the Evidence of Coverage for your VIVA Medicare Plus plan. This document is available on the web at www.vivamedicaremember.com under "Forms & Resources". The Evidence of Coverage provides detailed information on the plan’s service area, benefits, and cost-sharing, coverage determinations, grievance and appeals, the potential for contract termination, member and plan rights and responsibilities now and upon disenrollment, how to obtain an aggregate number of the plan's grievances, appeals, and exceptions, and out-of-network coverage.

Please see the table of contents in the front of the Evidence of Coverage to find the page number for the subject on which you need information.

Monthly premium. In 2008, all VIVA Medicare Plus plans have $0.00 monthly plan premium (members continue to pay the Part B premium to Medicare). This applies to all members including those who qualify for the low-income subsidy described below.

Members who enrolled in a Medicare Part D prescription drug benefit after their initial eligibility period may have to pay a late enrollment penalty imposed by Medicare.

Low-Income Subsidy: Extra Help for Members with Low Incomes.

Some people with Medicare can get extra help with prescription drug costs. Persons eligible for Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program qualify for the extra help automatically and do not need to apply. All others may apply with the Social Security Administration by mail, by telephone, or on the internet at: http://www.socialsecurity.gov.

Applications may also be filed at a local Medicaid office. Medicare Part D will provide a full drug subsidy with low co-payments to Medicare beneficiaries with incomes up to 135% FPL and limited resources. Medicare Part D will provide a partial subsidy of premium, deductible and co-insurance to Medicare beneficiaries with incomes up to 150% FPL and limited resources.

Click here for a link to the Mediare Rights Center chart titled "Extra Help Paying for Your Medicare Prescription Drug Coverage."

Pharmacy Network. The VIVA Medicare Plus Rx network includes over 1,200 pharmacies including local pharmacies and national chains. This network equals or exceeds requirements of the Centers for Medicare & Medicaid Services (CMS) for pharmacy access. Please review the information in the front of the pharmacy directory to learn more about how to fill prescriptions and when you can use an out-of-network pharmacy.

Pharmacy Directory

Formulary. Please review the information in the Formulary Introduction to learn more about the VIVA Medicare Plus Rx drug benefit including how to ask for an exception if your drug is not on the formulary, has a quantity limit, or is covered as a non-preferred drug.

Formulary Page

Formulary Changes. Each October, all current members are mailed a copy of the formulary for the next calendar year. To see changes made to the formulary since the time of the last annual mailing, click the link below. These changes are reflected in the current version of the formulary above.

Go to the Summary of Formulary Changes on the Formulary Page

Drugs Requiring Prior Authorization. We require you to get prior authorization for certain drugs that are on our formulary. These drugs have a “PA” next to them in the formulary. This means that you will need to get approval from us before you fill these prescriptions or we may not cover the drug. Ask your doctor to complete the form below and submit it for approval before you go to the pharmacy if you need a drug that requires prior authorization.

Prior Authorization Form

Transition Policy. New members in our plan may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. Members should talk to their doctors to decide if they should switch to an appropriate drug that we cover or request a formulary exception (which is a type of coverage determination) in order to get coverage for the drug. While these new members might talk to their doctors to determine the right course of action, we may cover the non-formulary drug in certain cases during the first 90 days of new membership. For each of the drugs that is not on our formulary or that have coverage restrictions or limits, we will cover a temporary 31-day supply (unless the prescription is written for fewer days) when the new member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). After the first 31-day supply, we will not pay for these drugs, even if the new member has been a member of the plan less than 90 days. If the new member is a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90-days for a new member of our plan. If a new member in a long term care facility needs a drug that is not on our formulary or subject to other restrictions, such as step therapy or dosage limits, but the new member is past the first 90-days of new membership in our plan, we will cover a 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

Complaint processes. A complete description of the grievance and appeals processes for your prescription drug benefit is found in your Evidence of Coverage. If you have complaints about your Part D prescription drug benefits, we encourage you to let us know right away.

Our Member Services staff is here to help if you have questions, concerns, or problems related to your prescription drug coverage. Please call Member Services at 205-918-2067 in Birmingham or 1-800-633-1542 toll free. TTY users, please call the Alabama Relay Service at 1-800-548-2546. Office hours are from 8:00 am -8:00 pm, Monday through Friday. A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint.

Appointing a Representative. You can name (appoint) someone to file a complaint for you. This person you name would be your representative. You can name a relative, friend, advocate, doctor, or someone else to act for you. Some other persons may already be authorized under state law to act for you.

If you want someone to act for you, then you and the person you want to act for you must sign and date a statement that gives this person legal permission to act as your representative. This statement must be sent to us at 1222 14th Avenue South, Birmingham, Alabama 35205. If you wish to appoint someone else to file a complaint for you, you may use VIVA Health’s Appointment of Representative form or the form developed by the Centers for Medicare & Medicaid Services (CMS).

VIVA Medicare Plus Appointment of Representative Form for Grievances
VIVA Medicare Plus Appointment of Representative Form for Appeals

Link to Medicare’s Appointment of Representative Form:
http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf

Grievances. A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with VIVA Medicare Plus or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

You can start the grievance process by calling Member Services at the number listed above.

You can also write to VIVA Medicare Plus, Attention: Medicare Member Appeals and Grievances, 1222 14th Avenue South, Birmingham, AL 35205 or you can fax your informal grievance to us at 205-558-7414.

Coverage Determinations. Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you must contact Member Services if you want to request a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. You have the right to ask us for an “exception,” which is a type of coverage determination, if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a non-preferred brand (Tier 3) drug at the lower preferred brand (Tier 2) copayment. If you request an exception, your physician must provide a statement to support your request. VIVA’s coverage determination and exception request form is included below. Links are also provided for Medicare’s versions of this form (one for members, one for providers). If we deny your request, we will send you a written decision explaining the reason why your request was denied. We may decide completely or only partly against you. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision.

Determination and Exception Form

Link to Medicare exceptions form for use by providers:
http://www.cms.hhs.gov/MLNProducts/downloads/form_exceptions_final.pdf

Link to Medicare exceptions form for use by people with Medicare:
http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/modelcoveragedeterminationrequestform.pdf

Appeals. An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You cannot request an appeal if we have not issued a coverage determination. If we issue an unfavorable coverage determination, you may file an appeal called a "redetermination" if you want us to reconsider and change our decision. The letter notifying you of the unfavorable coverage determination will explain how to file an appeal. If our redetermination decision on your appeal is unfavorable, you have additional appeal rights.