Important Information Regarding Your Medical and Prescription Drug Benefits

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.

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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.

Some people with Medicare can get extra help with prescription drug costs and their monthly plan premiums. If eligible, your monthly plan premium will generally be lower once you receive extra help from Medicare. 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 (1-800-772-1213), 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% of the Federal Poverty Level (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.

In some instances CMS systems may show that you are not eligible for the low income subsidy (LIS) or extra help even though you are. VIVA Medicare Plus is required to accept evidence that you present despite it contradicting the information received from CMS. Click the following link to see the Centers for Medicare & Medicaid Services webpage about the evidence you may submit to show your eligibility for the low-income subsidy (also know as Best Available Evidence) http://www.cms.hhs.gov/PrescriptionDrugCovContra/17_Best_Available_Evidence_Policy.asp

The table below shows what your monthly premium will be for VIVA Medicare Plus Plans (2010) if you are currently on LIS. The premiums listed do not include any Part B premium that you may have to pay. The premiums listed in the table are for both medical services and prescription drug benefits.

LIS VIVA Medicare Plus Rx Premier Monthly Premium (2010)
100%	$50.80
75%	$55.80
50%	$60.90
25%	$65.90

LIS VIVA Medicare Plus Rx Gold Monthly Premium (2010)
100%	$109.10
75%	$113.60
50%	$118.00
25%	$122.50

LIS VIVA Medicare Plus Rx, VIVA Medicare Plus Extra Value, VIVA Medicare Plus Rx Extra Care Monthly Premium (2010)
100%	$0.00
75%	$0.00
50%	$0.00
25%	$0.00

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Effective January 1, 2010, Viva Medicare Plus will cover standard and U.S. Food and Drug Administration (FDA) approved HIV screening tests for:

1. Annual Voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per United States Preventive Services Task Force (USPSTF) guidelines. To view the guidelines, please visit http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=229&.
2. Voluntary HIV screening of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester, and at labor.

No matter which Viva Medicare Plus plan you are on, 100% of the cost of the HIV screening will be covered. You must use a Viva Medicare Plus contracted provider in your provider system to administer the screening.

For more information concerning this memo, please click HERE.

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. For your convenience, VIVA Medicare Plus has provided links to both the printed pharmacy directory and the online pharmacy directory search.

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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 above. These changes are reflected in the current version of the formulary above.

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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 above and submit it for approval before you go to the pharmacy if you need a drug that requires prior authorization.

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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).

For new members residing in a long term care facility, 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 is 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.

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. You can also contact the numbers above for process or status questions.

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).

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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 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. You can also contact the numbers above for process or status questions.

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.

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 Medicare Plus' coverage determination and exception request form is included above. 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.

You can also request a coverage determination by writing to VIVA Medicare Plus, Attention: Medicare Member Appeals and Grievances, 1222 14th Avenue South, Birmingham, AL 35205 or you can fax your request to us at 205-558-7414.

You can request an expedited coverage determination by calling 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. You can also contact the numbers above for process or status questions.

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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.

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

You can submit an oral request for an expedited appeal by calling 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. You can also contact the numbers above for process or status questions.