Coverage Policies & Criteria

Coverage Policies & Criteria

General

The Viva Health Coverage Policies and Criteria contain Policies approved by Viva. Policies are based upon criteria from the Centers of Medicare & Medicaid Services (CMS), CMS approved drug compendia, or scientific evidence of merit for a particular medication. They represent the medical criteria identified by CMS and by research to be safe and effective. Please refer to the policy disclaimer. The applicable Viva policy is the policy that is in effect at the time of service.

Restrictions and Limitations

• Policies DO NOT determine the schedule of benefits. Rather, Policies are used in the process of determining whether a service may be medically necessary and appropriate or investigational.
• Payment will not be made for any use of these drugs outside of the criteria without prior authorization. The member may not be billed unless the member explicitly agrees in writing to be responsible for the charges in accordance with the contract/provider manual. Prior authorization will only be given if the provider demonstrates the intended use meets Medicare coverage guidelines.
• Policies are interpreted and applied in the sole discretion of the Plan.
• Policy application is subject to state and federal laws and specific instructions from Plan Sponsors of self-insured groups.
• Policies DO NOT constitute medical advice and DO NOT guarantee any results or outcomes.
• Current Procedural Terminology (CPT®) codes and descriptions are the property of the American Medical Association with all rights reserved.

Medicare Policies

National Coverage Determinations (NCD) and Local Coverage Determinations (LCDs) are a general outline of coverage that is in place for all Medicare Advantage health plans. NCDs and LCDs are made through an evidence-based process.

When there are no National or Local Coverage Determination policies available, Viva Medicare is allowed to use other evidence-based, recognized coverage criteria, such as the National Comprehensive Cancer Network. For the few services in which no criteria is available through these resources, CMS allows us to create an internal policy, using evidence-based sources.

Viva Health makes all of these criteria publicly available for anyone who wants to view them. The links to the resources are below:

• Viva Medicare's Medical Drug Policies

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• CMS Medicare Coverage Database (MCD)

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• National Comprehensive Cancer Network (NCCN)

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• Medical Preferred Drug Program with Step Therapy - Medicare

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Commercial Policies

• Commercial Pharmacy Coverage Determination Request Form

  Click Here

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• Specialty Drug List

  All unclassified drug codes (such as J3490, J3590, J8999 and J9999) require prior authorization. When requesting authorization for an unclassified drug, please submit the NDC#, Drug Name, and Dosage. Other Specialty Medications not listed on this list may be covered under your medical benefits. If covered, these drugs are subject to the cost-sharing specified in Attachment A and may be subject to Prior Authorization.

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• Viva Health Commercial Medical Drug Policies

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Medical Benefit Drugs

• Medical Benefit Drug Prior Authorization Form

  Click Here

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• Medical Preferred Drug Program

  Click Here

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