Prescription Drugs With Additional Requirements 

Limits on Our Medicare Prescription Coverages 

For certain prescription drugs, MVP has additional requirements for coverage or limits on our coverage. These requirements and limits help us control drug plan costs and ensure that our members use these drugs in the most effective way. A team of doctors and pharmacists developed these requirements and limits for our health plans to help us provide quality coverage to our members.

Why Are Certain Drugs Not Covered? 

Medicare rules do not allow Medicare Advantage plans to cover certain drugs, including: 

• Drugs purchased outside of the United States 
• Drugs used “off-label” (to treat conditions other than those the Food and Drug Administration has approved them to treat) 
• Drugs used to treat erectile dysfunction or for cosmetic purposes 
• Medications for cough or cold 
• Vitamins and mineral products 
  
  

Quantity Limits

For safety reasons and/or cost savings, certain drugs have limits on the amount that we will cover.

View the full list of medications with quantity limits for 2024 (PDF) or view the full list of medications with quantity limits for 2025 (PDF).

Prior Authorizations

For safety reasons and/or cost savings, certain drugs need approval from us before you can fill them.

View the full list of medications that need prior authorizations for 2024 (PDF) or view the full list of medications that need prior authorizations for 2025 (PDF).

Step Therapy

Medicare Part D drugs that require step therapy.

View the full list of medications that require step therapy for 2025 (PDF).

Coverage Determinations 

Coverage determinations let you ask us for exceptions to our policies about prescription drugs. Learn more about coverage determinations. 

MVP Health Plan, Inc. is an HMO-POS/PPO/HMO D-SNP organization with a Medicare contract and a contract with the New York State Medicaid program. Enrollment in MVP Health Plan depends on contract renewal. MVP Health Plan, Inc. has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 12/31/2024 based on review of MVP Health Plan’s Model of Care. Health benefit plans are issued by MVP Health Plan, Inc., an operating subsidiary of MVP Health Care, Inc. Not all plans available in all states and counties. Every year, Medicare evaluates plans based on a 5-star rating system. Out-of-network/non-contracted providers are under no obligation to treat MVP Health Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. For accommodations of persons with special needs at meetings, call 1-800-324-3899 (TTY 711).

Other physicians/providers are available in the MVP Health Care network. Gia virtual care services are available at no member cost-share for medical plans, including qualified high-deductible health plans (QHDHPs). Exceptions may apply for self-funded plans. In-person visits and referrals are subject to cost-share per plan. Members enrolled in a Medicare Rx plan without additional MVP medical coverage do not have access to MVP virtual care services through Gia. SilverSneakers is a registered trademark of Tivity Health, Inc. SilverSneakers On-Demand is a trademark of Tivity Health, Inc. ©2024 Tivity Health, Inc. All rights reserved. GetSetUp is a third-party provider and is not owned or operated by Tivity Health, Inc. (“Tivity”) or its affiliates. Users must have internet service to access online services. Internet service charges are responsibility of user.

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Last Updated: 10/1/2024