Forms & Policies - Medicare Advantage
Medicare Coverage Determination Request (English)
Medicare Coverage Determination Request (Spanish)
Medicare Part B (Medical) Drug Authorization Request Form
Medicare Prescription Drug Mail Order Form
Medicare Redetermination Request Form (English)
Medicare Redetermination Request Form (Spanish)
Part D Transition Policy
Pharmacy Member Reimbursement Form (English)
Pharmacy Member Reimbursement Form (Spanish)
View all Medicare forms
Prior Authorization & Step Therapy - Medicare Advantage
2024 Medical Preferred Drug List (Last Modified July 1, 2024)
2024 Medicare Part B Diabetes Supplies Covered (English)
2024 Medicare Part B Diabetes Supplies Covered (Spanish)
2024 Part D Prior Authorization Criteria (Last Modified November 1, 2024)
2024 Part D Step Therapy Criteria (Last Modified November 1, 2024)
Medicare Medical Benefit Drugs Requiring Prior Authorization
Medication Therapy Management Program
If you're in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program. MTM is a service offered by AvMed at no additional cost to you. This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.
Medication Therapy Management Program
Personal Medication List (PML)
Prescription Drug Coverage Frequently Asked Questions
What is the new Medicare Prescription Payment Plan?
Starting January 1, 2025, the Medicare Prescription Payment Plan is a new prescription payment option for members who have a Medicare plan, including Sentara Medicare plans.
This payment option spreads the cost of your prescriptions across capped monthly payments over a single calendar year. This payment plan does NOT lower your drug costs, but it can help with budgeting. It may not be the best choice for you if you get help paying for your prescription drug costs through programs like Extra Help from Medicare.
For more information, view the Medicare Prescription Payment Plan fact sheet.
Medicare Prescription Payment Plan Fact Sheet
Medicare Prescription Payment Plan Fact Sheet (Spanish)
Medicare Prescription Payment Plan Take Away Card
Medicare Prescription Payment Plan Take Away Card (Spanish)
How do I sign up for the Medicare Prescription Payment Plan?
You can opt in to the new payment plan during the Annual Enrollment Period (AEP) from October 15 to December 7 or any month throughout the plan coverage year.
You can sign up through our partner, Express Scripts by using one of these options:
Online: Log in to the AvMed Member portal, select Self-Services and Resources, then click Pharmacy Benefits and then Your RX Benefits. Once you are redirected to Express Scripts, select Account, then click Medicare Prescription Payment Plan. There will be options for more information including frequently asked questions about the program, a calculator to estimate costs, and instructions for opting in electronically
Phone: 1-866-845-1803 (TTY: 711), 24 hours per day, 7 days per week.
Mail: Download and print the Medicare Prescription Payment Plan enrollment form.
Prescription Payment Plan Enrollment Form
Prescription Payment Plan Enrollment Form (Spanish)
Mail the enrollment form to:
Express Scripts MPPP
P.O. Box 801101
Kansas City, MO 64180-1101
If you have questions about the Medicare Prescription Payment plan, please contact Express Scripts at 1-866-845-1803 (TTY: 711), 24 hours per day, 7 days per week.
