REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE
This form may be sent to us by mail or fax:
Address:
Viva Health, Inc.
417 20th Street North, Suite 1100
Birmingham, AL 35203
Fax Number:
(205) 449-2465

You may also ask us for a coverage determination by phone at 1-800-633-1542 (toll-free) or 1-800-548-2546 (toll-free TTY) or through our website at http://www.vivamedicaremember.com/.

Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.



Enrollee's Information


Name of prescription drug you are requesting (if known, include strength and quantity requested per month):

Drug Name Strength Quantity / Mo.
Add Your Drug Here (click the "+" button to add a line for each)...
Type of Coverage Determination Request

*NOTE: If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may use the attached "Supporting Information for an Exception Request or Prior Authorization" to support your request.



Use this file browser/upload to attach your supporting document
(please attach only a Word or Acrobat/PDF file):




Important Note: Expedited Decisions

If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.




Signature of person requesting the coverage determination (the enrollee, or the enrollee's prescriber or representative):

Supporting Information for an Exception Request or Prior Authorization

FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber's supporting statement. PRIOR AUTHORIZATION requests may require supporting information.

Prescriber's Information