MVP members may benefit from lower co-pays if selecting a formulary-preferred product. Some medications also require prior authorization or are subject to quantity limits or step therapy. See below for specific information about formularies, Medicare transactions and more.
See the full list of generic and name brand drugs covered by MVP Health Care plans that offer prescription drug coverage.
- 2020 MVP Commercial/Child Health Plus Formulary (PDF)—Applies to large groups; plans offered by employers with greater than 100 employees, MVP Child Health Plus, and Administrative Services Only plans.
- 2020 MVP Marketplace Formulary (PDF) —Applies to individuals who purchase their health plan on their own from New York State of Health—including the Essential Plan—or Vermont Health Connect or who purchase the plan directly from MVP. Also applies to small group employers with 100 employees or less.
- 2020 MVP Medicaid Formulary (PDF)—Applies to Medicaid plans.
- 2020 MVP Medicare Part D Individual Plan Formulary (PDF) —Applies to individuals who purchase their Medicare Advantage plan coverage directly from MVP.
- 2020 MVP Medicare Part D Employer-Based Plan Formulary (PDF) —Applies to individuals whose Medicare plan coverage is offered through a former employer or union group.
- New CMS Guidelines for Opiate Prescribing for Medicare Members
This information relates to the Prescription Drug Formularies generally, and may not describe your patient’s particular coverage. Check the Certificate of Coverage or Summary Plan Description for specific benefits, limitations and exclusions.
Medicare High Risk Medications
MVP has created a high risk medication report by prescriber for the most frequently prescribed medications that may cause harm in the elderly population. The report contains the member’s name, medication prescribed, quantity dispensed, date of last fill and the pharmacy where the medication was filled. The goal of the report is to make the prescriber aware of these medications and offer potential alternatives (if clinically appropriate in the elderly population).
Download the MVP Medicare High Risk Medications Report:
TransactRx Online Billing for Part D Vaccines and Administration
Providers now have an online option for processing Medicare Part D vaccine claims electronically. TransactRx Part D Vaccine Manager, a product of Dispensing Solutions Inc., provides physicians with real time claims processing for in-office administered vaccines. This new online resource helps to reduce the current challenges in providing Medicare Part D vaccines and vaccine administration reimbursement to our members.
How to Enroll
Enrollment in TransactRx is available at no cost to physicians or patients. After completing a simple one-time online enrollment process at http://enroll.mytransactrx.com physician offices can:
- Verify members’ eligibility and benefits in real-time
- Advise members of their appropriate out-of-pocket expense
- Submit vaccine claims electronically
- Receive reimbursement information in real-time
Physicians should select an authorized staff member who is most likely to be the primary user of the system to enroll the practice. This person should be prepared to provide the following information about the practice:
- Tax identification number
- National provider identifier(s) (NPI)
- Medicare ID number
- Drug Enforcement Administration (DEA) number
- State medical license number
When using TransactRx Part D Vaccine Manager to file a Medicare Part D vaccine claim, physicians will be reimbursed according to MVP Health Care’s reimbursement schedule, less the member’s co-pay.
Note: The member’s co-pay is not always a flat dollar amount. It could be a percentage co-pay or even full price depending on where the member is in their Part D pharmacy benefit (for example: if a member is in their deductible phase or coverage gap, they could be responsible for 100% of the cost for the vaccine and its administration).
TransactRx cannot be used to bill the administration and cost of Medicare Part B covered vaccines (e.g. influenza vaccine, pneumococcal vaccine, or Hepatitis B vaccine for high or intermediate risk individuals).
For questions related to Enrollment and claims processing, call Dispensing Solutions’ customer support center at 1-866-522-3386 (EDVM). You can also contact the Professional Relations Service Center at 585-325-3114 or 1-800-999-3920, or email us at firstname.lastname@example.org.
Online Billing Option for Part D Vaccines and Administration
eDispense Part D Vaccine Manager, a product of Dispensing Solutions Inc., is a web portal that provides physicians with real-time claims processing for in-office administered vaccines. This online resource helps to reduce the current challenges in providing Medicare Part D vaccines and vaccine administration reimbursement to our members.
Medicare Part D Information
A list of additional links, drug coverage information, CVS Caremark® details and more can be found here.
Most Requested Forms
Below you will find a selection of our most commonly referenced Pharmacy forms. You can find the full range of Provider forms here.
Prior Authorization Forms
- NYS Medicaid Prior Authorization Request Form for Prescriptions (PDF)
- Prior Authorization Request Form for Medication (PDF)
Medicare Part D Forms
MVP Mail Order Program
MVP members who have prescription drug coverage may be able order maintenance drugs—drugs taken on a regular basis—from CVS Caremark Mail Service Pharmacy, MVP’s mail service pharmacy vendor. Up to a 90-day supply of medication can be ordered through this program. Once a member’s prescription is on file with CVS Caremark Mail Service Pharmacy, members can order refills by mail, phone or online and have their medication delivered to their door. Note: This service is not available to all MVP members.
To find out if a medication is available from CVS Caremark Mail Service Pharmacy, choose the appropriate formulary; if a drug or drug class has an * next to it, that drug or all drugs in that class are available through mail service. An MVP member who is taking a maintenance drug may ask you to write two prescriptions, one for up to a 30-day supply to be filled at a local pharmacy, and one for up to a 90-day supply to be filled through CVS Caremark Mail Service Pharmacy.
Members interested in finding out more about the mail service program can contact MVP’s Customer Care Center at the phone number listed on the back of their Member ID card.
Find information on drug recalls and updates.