Member Resources

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.

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.

Who sends the surveys?

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.

Consumer Assessment of Healthcare Providers and System (CAHPS) Survey

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.

Health Outcomes Survey (HOS)

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.

Why do the surveys matter?

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.

If you receive a survey in the mail, please fill it out and send it in.

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:

2025 MTM Program Criteria

1. Take eight (8) or more maintenance drugs.

   
   

2. AND Have three (3) or more of the following long-term health conditions:

   • Alzheimer's disease
   • Bone disease/arthritis
   • Congestive heart failure (CHF)
   • Diabetes
   • Dyslipidemia

   • End-stage renal disease (ESRD)
   • Hypertension
   • Mental health
   • Respiratory disease
   • HIV/AIDS
   
   

3. AND Medications gross cost of at least $5,330 for calendar year 2024 or $1,623 for calendar year 2025 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 an MTM call center or 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, 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. This is called a Targeted Medication Review (TMR). If any issues are found, members' prescribers will be contacted by Viva Medicare to discuss the issue and solutions.

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.

High drug costs are a big concern for many members. In 2025, Viva Medicare is paying a higher share of your prescription drug costs to help put money back in your pocket. You will no longer have a coverage gap (called a “donut hole”), and will pay no more than $2,000 in out-of-pocket costs for Part D drugs.

If you do not take many prescription drugs, you may never reach $2,000 in out-of-pocket drug costs. Members who are prescribed several drugs or take a high-cost drug may reach this amount early in the year. These members may benefit from a new program called the Medicare Prescription Payment Plan (M3P).

What is M3P?

M3P is a new government program that lets Medicare members make monthly payments for high-cost prescription drugs throughout the year (January – December) instead of paying the full amount at the pharmacy when the prescription is filled. While this program may be helpful for some members, it’s important to know all the facts and your options before enrolling in M3P.

How does M3P work?

You will get a letter if your out-of-pocket drug costs from January to September 2024 were more than $2,000. The letter will tell you about M3P and how to enroll in the program. If you are prescribed a drug that makes your out-of-pocket cost $600 or more, your pharmacist may also tell you about M3P when the prescription is filled.

Viva Medicare is working with CVS Caremark to manage M3P enrollments and billing. Once you enroll in M3P, you will be set up on a monthly payment plan. Each month, you pay CVS Caremark by sending a check in the mail or paying online. This payment must be received by the due date. Your payments begin the month after your prescription drug is filled at the pharmacy, and a final payment is due by January of the following year.

It’s important to know that your monthly payment can change to a higher amount if new prescription drugs are filled during the year and added to your M3P payment plan.

Is M3P a good fit for me?

Enrolling in M3P does not save you money or lower the cost of the drugs. The program simply allows you to spread your out-of-pocket prescription payments over time. This program is NOT a good fit for you if:

• You get Extra Help from Medicare or are enrolled in the Viva Medicare Extra Value (HMO SNP) plan or Viva Medicare Extra Care (HMO SNP) plan.
• You qualify for a Medicare Savings Program.
• Your yearly drug costs are low.
• Your drug costs are the same each month.
• You’re considering signing up for the payment option late in the calendar year (after September).
• You don’t want to change how you pay for your drugs.

M3P may be a good fit for you if you are prescribed a high-cost drug early in the year, or take several costly drugs each month.

Sample Monthly Payments

Note: These sample payment plans are used to explain possible scenarios; your payment plan may look different with higher or lower monthly payments, based on the drugs you are prescribed.

In the example below, your out-of-pocket prescription drug cost is $500 in January, February, March, and April and you pay that amount at the pharmacy when you pick up your prescription. After spending $500 per month for four months, you reach your maximum out-of-pocket cost of $2,000 and do not have to pay any more Part D prescription drug costs for the rest of the year.

If you choose to participate in M3P, you will pay the amounts shown below:

In this example below, new prescription drugs are filled throughout the year and added to your M3P account. While no out-of-pocket costs are paid at the pharmacy when you fill your prescription, your monthly payments increase the last five months of the year.

In this example, as new prescription drugs are added throughout the year, the monthly payment gets higher at the end of the year. M3P may not be a good option for you if you do not want higher payments during the holiday season.

How to sign up for M3P

If you think M3P is a good option for you, take these steps:

1. Fill out the enrollment form found in your member guide or go online to Caremark.com/MPPP to complete the form.
2. You will get a letter confirming your enrollment. The letter will show your payment plan and due date. Remember, your monthly payments will get higher if more prescriptions are added during the year.

Other Ways to Save on Drug Costs

Many members qualify for savings and don’t realize it. If you have limited income and resources, call us at 1-800-633-1542 or toll-free, TTY users please dial 711 to see if you qualify for one of these programs:

Extra Help: A Medicare program that helps pay your Medicare drug costs. Visit medicaid.alabama.gov to find out if you qualify and apply. You can also apply with your State Medical Assistance (Medicaid) office. Visit Medicare.gov/basics/costs/help/drug-costs to learn more.

Medicare Savings Programs: State-run programs that might help pay some or all of your Medicare premiums, deductibles, copayments, and coinsurance. Visit medicare.gov/basics/costs/help/medicare-savings-programs to learn more.

Manufacturer Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs (PAPs)): Programs from drug manufacturers to help lower drug costs for people with Medicare. Visit cms.gov/medicare/coverage/prescription-drug-coverage/patient-assistance-program to learn more.

It’s important to us that you fully understand how M3P and the monthly payment structure works before signing up for this program.

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.

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).

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.

Viva Medicare Extra Value, Viva Medicare Extra Care, Viva Medicare Classic, Viva Medicare Infirmary Health Advantage and Viva Medicare Plus

Viva Medicare Premier

Viva Medicare Prime

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.

Mailing Address:
Viva Medicare
Attention: Medicare Member Appeals and Grievances Coordinator
417 20th Street North Suite 1100
Birmingham, AL 35203
Fax: 205-933-1239

While you are a member of our plan, you must continue to get your Medicare covered services through Viva Medicare.

• You should continue to use the Viva Medicare network of pharmacies to get your prescriptions filled (if you have prescription drug coverage through our plan).
• If you are hospitalized on the day your membership ends, your hospital stay will usually be covered by Viva Medicare until you are discharged.