Coverage, Claims & Billing

Asking for a Coverage Decision

Coverage Decision for Medical & Services

A coverage decision is a decision we make about your benefits and coverage. You or your doctor can contact us and ask for a coverage decision. You can also ask us for a coverage decision if your doctor refuses to provide/arrange medical care you think you need. To ask for a coverage decision, please call, fax or write Member Services and we will give you an answer in a timely manner. To view contact information please click here. You may contact Medicare to file a complaint by clicking here.

Coverage Decision for Part D Prescription Drugs

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 can contact MMS (Medicare Member Service) or talk to your doctor to make the request. 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 you believe you should not have to meet prior authorization or other utilization management requirements, or you believe you should get a non-preferred drug at the lower preferred drug copayment. If you request an exception, your physician must provide a statement to support your request.

Viva Medicare's coverage determination and exception request form is below. 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
Attention: Pharmacy
417 20th Street North
Suite 1100
Birmingham, AL 35203

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 711. Regular office hours are from 8 am - 8 pm, Monday through Friday. Extended office hours (Oct. 1 - Mar. 31) are from 8 am - 8 pm, 7 days a week. You can also contact the numbers above for process or status questions.

Part D Drug Reimbursement Claim Request

Use this form to request payment for a Part D drug paid for out-of-pocket. Download the form and follow the instructions to submit your request to CVS Caremark.