You can ask MVP to cover a drug for a lower cost, remove an additional requirement or limit, or cover a drug that is not listed on the Formulary. This process is called a coverage determination.

How do I Request a Coverage Determination?

To request a coverage determination, complete our coverage determination form, available as a printable .pdf or a fillable web form. There are several types of exceptions you can ask us to make.

You can ask us to cover a drug that is not listed on the Formulary. Please note that MVP cannot approve a Formulary Exception for medications that Medicare does not cover, such as cyanocobalamin injection (Vitamin B-12 injection).

You can ask us to cover a Formulary drug for a lower cost. For example, if your drug is listed in our Tier 4 Non-Preferred Drugs, you can ask us to cover it at the cost-sharing amount that applies to drugs on the Preferred Brand Name Drugs Tier 3 instead. This would lower the amount you must pay for your drug. Note that MVP cannot lower the cost-sharing level of a Tier 5 Specialty drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, MVP Health Care limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, we will only approve your request if alternative drugs included on the Formulary, lower cost drugs, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

All requests should include a statement from your prescriber or doctor supporting your request. MVP must make a decision on your request within 72 hours of receiving your prescriber’s supporting statement. You can request an expedited (fast) decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

If MVP does not approve your request, you can appeal our decision and ask for a redetermination using MVP’s redetermination request form. For more information, read Grievance and Appeals Information (PDF)

Transition Supply

If a drug you take is not listed on the Formulary or includes extra rules or restrictions, you may be able to get a temporary supply of your prescription. This gives you time to work with your doctor to decide the right course of action for you.

To be eligible for a temporary supply you must meet at least one of the following conditions:

  • The drug you have been prescribed is no longer on the Formulary, or
  • The drug you have been prescribed is now restricted in some way.

For members who were in an MVP Medicare plan last year and do not live in a long-term care facility, MVP will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.

For members who are new to an MVP Medicare plan and do not live in a long-term care facility, MVP will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.

For members who are new to the plan and live in a long-term care facility, MVP will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 31-day supply or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan, up to a maximum of a 31-day supply.

For members who have been in the plan for more than 90 days, live in a long-term care facility and need a supply right away, MVP will cover one 31-day supply or less if your prescription is written for fewer days. This may be in addition to the above long-term care transition supply.

For more details, read MVP’s Transition Supply Policy (pdf)

Note: Certain drugs are excluded by Medicare and cannot be covered by MVP per government regulations, including vitamins, over-the-counter products, cosmetic agents, weight loss/weight gain medications, erectile dysfunction medications, DESI drugs, and unapproved drugs.