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When you join Viva Medicare, you choose one doctor to be your Primary Care Physician (PCP).
You will use the specialists and hospital associated with your PCP when you need medical care. This is called your Provider System.
The Viva Medicare Provider Systems are listed below. Click on a Provider Directory to see a list of doctors and hospitals who are in that provider system. You may also use the "Provider Search" feature below to search by a doctor's last name or specialty.
The national Viva Medicare Pharmacy network for Viva Medicare Me, Viva Medicare Plus, Viva Medicare Prime, Viva Medicare Premier, Viva Medicare Extra Value, HH Viva Medicare Classic, HH Viva Medicare Preferred, and HH Viva Medicare Extra Care includes an extensive network of both local pharmacies and national chains.
The national Viva Medicare networks equal or exceed the requirements of the Centers for Medicare & Medicaid Services (CMS) for pharmacy access. Please review the information in the front of the pharmacy directory to learn more about how to fill prescriptions and when you can use an out-of-network pharmacy.
To learn more about Viva Medicare’s pharmacy benefits, view our Pharmacy Benefit Guide.
Formularies (lists of covered drugs) offer members access to both generic and brand name drugs. The formulary includes prescription drugs in every therapeutic class and category. Please review the information in the formulary introduction to learn more about the Viva Medicare Rx drug benefit – including how to ask for an exception if your drug is not on the formulary, has a coverage restriction, or is covered as a non-preferred drug.
NOTE: Look up your medication in the index in the back. Then go to that page number to see the drug's tier. The amount you pay for drugs depends on which Viva Medicare plan you are on. Copays are listed in the front of your formulary.
Each October, all current members who are on a plan that includes Part D coverage are notified that the formulary for the next calendar year is available on our website. Members can find information regarding any mid-year non-maintenance formulary changes to the printed formulary, as well as Prior Authorization and Step Therapy criteria, by looking below or calling Member Services. You can also review your monthly Part D Explanation of Benefits (EOB) to see which of the drugs you are currently taking are coming off the Viva Medicare formulary. If you want the formulary for your plan mailed to you, call Member Services.
Important Message About What You Pay for VaccinesOur plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
Important Message About What You Pay for InsulinYou won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
*Members enrolled in Viva Medicare Extra Value and Viva Medicare Extra Care that receive “Extra Help” (limited income subsidy) will pay $0 for insulin covered by our plan.
We require you to get prior authorization for certain drugs that are on our formulary. These drugs have a "PA" next to them in the formulary. This means that you will need to get approval from us before you fill these prescriptions or we may not cover the drug. Ask your doctor to complete the form below and submit it for approval before you go to the pharmacy if you need a drug that requires prior authorization.
If your drug is not on the Drug List or is restricted, here are things you can do:
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. To be eligible for a temporary supply, you must meet one of changes listed in Requirement 1 and one of the situations described in Requirement 2 below:
We will cover a temporary supply of your drug during the first 90 days of the calendar year (current members) or during the first 90 days of your membership (new members). This temporary supply will be for a maximum of 30 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. The prescription must be filled at a network pharmacy.
We will cover a temporary supply of your drug during the first 90 days of the calendar year (current members) or during the first 90 days of your membership (new members). The total supply will be for a maximum of 91 days and may be up to a 98-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 91 days of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
Current members that experience unplanned transitions as a result of a change in treatment settings (e.g., such as moving from a hospital to a long term care facility, to home or to a skilled nursing facility or those leaving a skilled nursing facility) can request a formulary exception to continue their current non-formulary drug. In these situations, the plan will consider allowing a member a one-time temporary or emergency supply so that the member does not experience a coverage lapse while proceeding through the exceptions process.
To ask for a temporary supply, call Member Services at the number on the bottom of this page. During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.
It’s important to us that you have the best experience possible with Viva Medicare and your doctors. We all work together as part of your health care community to make sure you get healthy, stay healthy, and live your best life.
Each year, surveys are sent to a random selection of Medicare members across the nation. The surveys are like a report card that lets us know what you think about the service we provide, how well your doctors take care of you, and how you feel about your overall health. These surveys help us make your experiences with Viva Medicare and your doctors even better.
The government agency that runs Medicare, called the Centers for Medicare & Medicaid Services, or CMS, and the National Committee for Quality Assurance, or NCQA, require that two surveys be sent each spring to some members in every Medicare Advantage plan.
The Consumer Assessment of Healthcare Providers and System, or CAHPS, survey is sent by the Agency for Healthcare Research and Quality. This survey asks questions about your experiences with your doctors, hospitals, home health care agencies, prescription drug plans, and your health insurance plan. The survey helps CMS compare health plans and see which ones are doing a great job of helping members improve their health and which ones are not.
The Health Outcomes Survey, or HOS, looks at how well health plans, like Viva Medicare, help members get healthy or stay healthy over time. Members who get this survey will get a follow-up survey a couple years later. The results are compared and health plans get a rating based on members feeling better, the same as, or worse than expected.
CMS uses these surveys and key health care measures, like getting preventive screenings and tests for cancer and other diseases, managing diabetes and high blood pressure, and providing great customer service to give each Medicare health plan a rating from 1 - 5 Stars. 5 Stars is the highest possible rating.
Viva Medicare is the only plan in Alabama to earn a 5-Star rating two years in a row! This shows that CMS believes Viva Medicare is one of the top plans in the state and the nation. 5 Star plans get extra bonus money that is used to give you better benefits and savings.
You’ll have access to thousands of gyms where you can participate in strength training, yoga, Zumba, or use treadmills, elliptical machines,
free weights, and more at your local gym. Or if you are more comfortable exercising at home, you can have the gym come to you with at-home,
digital options. You can learn more about Silver&Fit here or search for
your local gym below. On the Silver&Fit homepage click the Access Fitness Center button.
The Medication Therapy Management (MTM) Program supports VIVA MEDICARE members with complex, long-term health problems by helping them take their prescription drugs in a safe and structured manner.
Select at-risk members are automatically enrolled in the MTM Program. There is no cost to the member. To be selected for the MTM Program, members must meet VIVA MEDICARE's Drug Management Program guidelines and/or ALL of the following three (3) standards:
Take eight (8) or more drugs from the following specific Part D drug classes:
AND Have three (3) or more of the following long-term health conditions:
AND Expect to spend at least $4,935 for calendar year 2023 or $5,330 for calendar year 2024 on prescription drugs.
Members selected for the MTM Program are sent a letter welcoming them and letting them know they have been enrolled. They will get a call from either a partnering local pharmacy, an MTM call center, a VIVA MEDICARE pharmacist, or a qualified provider to go over the prescriptions and/or over-the-counter drugs the member is taking. This is called a Comprehensive Medication Review (CMR) and takes about 30 minutes. It is usually offered once each year.
A specially trained pharmacist or other qualified provider will review the member's drug list to see if there are any problems with certain drugs being taken together. If problems are found, we will work with the member and prescriber to see what drugs, if any, should be changed.
After the CMR, members will be mailed a Medication Action Plan that outlines steps the member should take to get the best results from the prescriptions and/or over-the-counter drugs the member is taking. Members will get a Personal Medication List that helps keep track of each drug and when/how it should be taken. This keeps members safe and ensures the drugs are as effective as possible.
In addition to the CMR, members may get a Targeted Medication Review (TMR). During a TMR, pharmacy claims are reviewed every three months to make sure there are not any new or ongoing drug therapy problems, like a potential safety problem and/or a gap in getting prescriptions filled. If any issues are found, members will be contacted by VIVA MEDICARE or the prescriber.
All members enrolled in VIVA MEDICARE's MTM Program will be taught how to safely dispose of (throw away) any prescription drugs that are controlled substances. A controlled substance is a prescription drug that can cause physical and mental dependence. These drugs need to be disposed of more carefully through local take-back programs and proper in-home disposal.
Enrolled members can disenroll from the MTM Program any time during the year or stay enrolled but decline some services.
For more information on VIVA MEDICARE's Medication Therapy Management Program, please call our member services department at 1-800-633-1542 or 205-918-2067. TTY users, call 711. They can take your call Monday-Friday, 8 am - 8 pm. From October 1 to March 31, they are open seven days a week, 8 am - 8 pm.
Effective January 1, 2022, Viva Health added a Medical Preferred Drug Program with Step Therapy requirements for our Medicare Advantage members. The link below is the list of drugs that will be subject to these requirements.
You can name (appoint) someone to file a (grievance) or appeal for you. This person you name would be your representative. To appoint a representative, complete the appropriate form below and mail (417 20th Street North, Suite 1100, Birmingham, AL 35203) or fax (205-449-6023) it to Medicare Enrollment.
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.
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:
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.
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.
The Centers for Medicare & Medicaid Services (CMS) sometimes changes the coverage rules that apply to an item or service under Medicare. Such changes may include what benefits and services are covered, what benefits and services are changing, and what Medicare will pay for an item or service. When this happens, CMS issues a National Coverage Determination or NCD. You can view the CMS annual database where all NCDs are posted by year here.
The Centers for Medicare & Medicaid Services (CMS) is the government agency that manages Medicare Advantage plans throughout the United States. CMS limits Medicare coverage to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). They require health plans, like Viva Medicare, to base decisions about covering items, services, or medications on National and Local Coverage Determinations.
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 evidenced based, recognized coverage criteria, such as the National Comprehensive Cancer Network , or our vendor InterQual®. For the few services in which no criteria is available through these resources, CMS allows us to create an internal policy, using evidenced-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:
If you have any questions or need help finding a specific criteria, please call Member Services at 1-800-633-1542, TTY: 711.
Our hours are 8am - 8pm, Monday - Friday (from October 1 to March 31: 8am - 8pm, 7 days a week).
† Premium amount depends on county of residence and low income subsidy, if applicable. See section on low income subsidy for more information.
Members continue to pay the Part B premium to Medicare. Members who enrolled in a Medicare Part D prescription drug benefit after their initial eligibility period may have to pay a late enrollment penalty imposed by Medicare.
If you are a current Viva Medicare member and would like to change to one of our other Viva Medicare plans, complete the Plan Change form below and mail it to the address listed at the bottom of the form. Please be aware that you can change plans only at certain times during the year. Between October 15th and December 7th each year, anyone can change plans. Generally, you may not make changes at other times unless you meet certain special exceptions, such as if you get Extra Help for prescription drugs or qualify for a Medicaid program.
Some people with Medicare can get extra help with prescription drug costs and their monthly plan premiums. If eligible, your monthly plan premium will generally be lower once you receive extra help from Medicare. Persons eligible for Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program qualify for the extra help automatically and do not need to apply. All others may apply with the Social Security Administration by mail, by telephone (1-800-772-1213), or at: http://www.socialsecurity.gov.
Applications may also be filed at a local Medicaid office. Medicare Part D will provide a full subsidy with low co-payments to Medicare beneficiaries with incomes up to 135% of the Federal Poverty Level (FPL) and limited resources. Medicare Part D will provide a partial subsidy of premium, deductible, and co-insurance to Medicare beneficiaries with incomes up to 150% of the FPL and limited resources.
In some instances, CMS systems may show that you are not eligible for the low income subsidy (LIS) or extra help even though you are. Viva Medicare is required to accept evidence that you present despite it contradicting the information received from CMS. You can view the Centers for Medicare & Medicaid Services webpage here about the evidence you may submit to show your eligibility for the low-income subsidy (also known as Best Available Evidence).
The table below shows what your monthly premium will be for Viva Medicare Plans if you are currently on LIS. The premiums listed do not include any Part B premium that you may have to pay. The premiums listed in the table are for both medical services and prescription drug benefits.
Our Member Services staff is here to help if you have questions, concerns, or problems. You can reach 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 send a fax to us at 205-558-7414 or write us at:
Your health and satisfaction are important to us. You can contact Member Services to check the status of a request or to ask questions about our processes. Member Services can also help you make a request for a coverage decision or file a complaint or appeal.
You can get summary information about the complaints (grievances) and appeals we have received. To request this summary information, please call (205-918-2067) fax (205-558-7414) or write Member Services (417 20th Street North, Suite 1100, Birmingham, AL 35203).
Viva Medicare reaches out to our members for many reasons. We want to help you maintain your health and make sure you’re getting the most out of your benefits. When you receive a call from Viva Medicare, it will be from one of our nurses, pharmacists, employees, or a trusted vendor. You may also receive an automated call from us. We will do the following things:
When you provide your phone number (cellular or landline) to us, you agree and consent for us to contact you at that phone number for certain health care calls (including voice messages made by an auto-dialer or a pre-recorded voice message). You may cancel (revoke or opt-out of) this consent by contacting our Member Services Department.
Viva Medicare will never ask you for your financial information on these calls. If you want us to contact you in a different way or you are not sure that the call you are receiving is legitimate, you should call Viva Medicare Member Services at 1-800-633-1542 or 205-918-2067 (Monday-Friday, 8am-8pm).
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To give information about Health Screenings and services based on your age and/or health.
*A staff member from your PCP’s office may call as well as Viva employees.
We will help set up appointments that you need. In some cases, we may schedule an in-home visit.
The appointments will be for services like an Annual Check Up, Mammogram, Vision Screening, Colon Cancer Screening, Flu Shot, and/or Diabetes tests.
If your PCP is hosting a “Viva Day”, you may be contacted to accept an appointment for your annual physical or, if diabetic, an eye scan.
To review your current medications to make sure you are taking the right medicines in the right way. We will also remind you when it is time to fill your prescriptions.
*CVS/Caremark may call you. They administer the prescription benefits on behalf of Viva Medicare.
We want to make sure that you are getting your medications on time and using them safely. In addition, the Centers for Medicare & Medicaid Services (CMS) requires Viva Medicare to complete medication review activities.
To speak with you about your general health.
We are required to complete a Health Risk Assessment (HRA) on all new members and yearly for many members.
The HRA is a series of questions about your health. It helps us develop a care plan and determine if we have support services that you may need to stay healthy.
To check on you after you’ve been in the hospital or to help you manage a serious health issue.
We want to make sure you are doing well after coming home from the hospital. When we call we may ask about your medications, your doctor’s instructions after discharge, and your follow up appointments.
If you have a serious health condition or multiple chronic conditions, we want to help. We have a variety of different health professionals including nurses and pharmacists to make sure you’re getting the services you need.
To invite you to an event Viva Medicare is hosting.
We hold regular events for our members at our Viva Health Café locations. You can attend events such as healthy cooking classes, exercise classes, bingo, crafts days, and much more.
To ask you about your satisfaction with Viva Medicare and your health status.
*The call could be from The Centers for Medicare & Medicaid Services (CMS) or be an electronic call from Viva Medicare.
Each year CMS selects a sample of our members to ask about their satisfaction with Viva Medicare, our doctors, and other issues that may affect their health and well-being. This helps us address issues and understand how well we are serving you.
We do not know who CMS selects for these member surveys, but the results impact our Star Rating so we appreciate your participation in the surveys if you are asked.
A complaint (grievance) does not involve a denied claim or a service request. You can file a complaint (grievance) if you have any type of problem with Viva Medicare, one of our network providers, or one of the companies who provide Viva Medicare benefits.
An appeal is how you ask Viva Medicare to review and change a decision we made about your coverage.
To make a complaint (grievance) or an appeal, please complete the Consumer Affairs form linked here and mail or fax the form to Viva Medicare (see contact information below). You can also call Member Services (see contact information below). For more information, please see Chapter 9 of your Evidence of Coverage for your plan above.
Attention: Medicare Member Appeals and Grievances Coordinator
417 20th Street North Suite 1100
Birmingham, AL 35203
While you are a member of our plan, you must continue to get your Medicare covered services through Viva Medicare.
You may voluntarily end your membership in Viva Medicare by submitting a written request during certain times of year, known as enrollment periods.
All members have the right to leave the plan during the Annual Enrollment Period (AEP) and during the annual Medicare Open Enrollment Period (OEP) by submitting a completed and signed disenrollment form or a written request. Please contact the plan for more information on how to submit a disenrollment request.
During this time, you can keep your current coverage with Viva Medicare or make changes to your coverage for the upcoming year. If you make a change during AEP, your coverage will end when your new plan’s coverage begins on January 1st.
During this time, you can cancel your enrollment with Viva Medicare and make one change to a different plan or switch back to Original Medicare (and join a stand-alone Medicare Prescription Drug Plan). Any changes you make will be effective the first of the month after the plan gets your request.
You generally cannot make other changes during the year unless you meet special exceptions (e.g., you have Medicaid or are eligible for Extra Help, etc.). Please refer to your Evidence of Coverage for more details about these exceptions.
We must end your membership in our plan if any of the following happen:
We cannot ask you to leave our plan for any reason related to your health. If we end your membership in our plan, we must tell you our reasons in writing. Viva Medicare must also explain how you can make a complaint about our decision to end your membership. Please refer to your Evidence of Coverage for information about how to make a complaint.
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