Viva Medicare Resources

Authorization/Pre-Certification Forms

• Imaging Request Form

  Download

• Referral Authorization Form

  Download

• DME Form

  Download

• Inpatient/Outpatient Precertification Form

  Download

• Rehabilitation Precertification Forms

  Download

• SNF/Rehab Discharge Documentation

  Download

• Provider Reference Guide

  Download

Behavioral Health

• Psychological-Neurological Testing Request Form

  Download

• Transcranial Magnetic Stimulation Authorization Request Form

  Download

• Electroconvulsive Therapy (ECT) Authorization Request Form

  Download

• Mental Health Continued Stay Review Fax Form

  Download

• Substance Abuse Initial Review Fax Form

  Download

• Substance Abuse Continued Stay Review Form

  Download

• Discharge Orders Fax Form

  Download

Care Plans

• QI - Care Plan (Member)

  Click Here

• QI - Care Plan (Cancer)

  Click Here

• QI - Care Plan (Congestive Heart Failure)

  Click Here

• QI - Care Plan (Diabetes)

  Click Here

• QI - Care Plan (High Blood Pressure)

  Click Here

• QI - Care Plan (Stroke)

  Click Here

Pharmacy

• Medical Benefit Drug Prior Authorization Form

  Download

• Medicare Part D - Coverage Determination Form

  Download

• Hospice Beneficiary - Medicare Part D Request Form

  Download

• Medical Drug Policies

  View

• HelpScript FAQ

  Download

• CMS Medicare Coverage Database (MCD)

  View

• National Comprehensive Cancer Network

  View

• Medical Preferred Drug Program with Step Therapy - Medicare

  Download

• Viva Medicare Special Needs Plan Model of Care (SNP MOC) Provider Training

  View

• Medicare Part D Opioid Policies - Information for Prescribers

  Download

• Medicare Part D Opioid Policies - Information for Pharmacists

  Download

• Member Opioid Educational Flyer

  Download

• Member Opioid Educational Letter

  Download

• Real-Time Prescription Benefit Overview

  Download

• FAQ Prescription Benefits

  Download

• Compatible EHR Systems

  Download

• 2024 Diagnosis Code Guide

  Download

• 2026 Viva Medicare Plus, Premier, Extra Value, Classic, Extra Care, and Infirmary Health Advantage Plans Pharmacy Directory

  Download

• 2026 Viva Medicare Extra Value and Extra Care Plans Formulary (List of Covered Drugs)

  Download

• 2026 Viva Medicare Plus, Premier, Classic, & Infirmary Health Advantage Plans Formulary (List of Covered Drugs)

  Download

• 2026 Viva Medicare Extra Value and Extra Care (SNP) Step Therapy Criteria

  Download

• 2026 Viva Medicare Plus, Premier, Classic, & Infirmary Health Advantage Plans (Non-SNP) Step Therapy Criteria

  Download

• 2026 Viva Medicare Plus, Premier, Classic and IH Advantage (Non-SNP) Cumulative Changes

  Download

• 2026 Viva Medicare Extra Value and Extra Care (SNP) Cumulative Changes

  Download

• 2027 Viva Medicare Plus, Premier, Extra Value, Healthy Living, Classic, Extra Care, and Infirmary Health Advantage Plans Pharmacy Directory

  Download

• 2027 Viva Medicare Extra Value and Extra Care (SNP) Formulary

  Download

• 2027 Viva Medicare Plus, Premier, Classic, & Infirmary Health Advantage Plans (Non-SNP) Formulary

  Download

• 2027 Viva Medicare Healthy Lifestyles Plan (C-SNP) Formulary

  Download

• 2027 Viva Medicare Extra Value and Extra Care (SNP) Step Therapy Criteria

  Download

• 2027 Viva Medicare Plus, Premier, Classic, & Infirmary Health Advantage Plans (Non-SNP) Step Therapy Criteria

  Download

• 2027 Viva Medicare Healthy Lifestyles Plan (C-SNP) Step Therapy Criteria

  Download

Other

• Provider Compliance Training

  Download

• InterQual Transparency Tool

  View

• EFT - Electronic Payment Flyer

  Download

• Request for Reopening vs. Appeal

  Download

• Waiver of Liability Statement Form

  Download