CurrentMVP Health CarePolicy N/A

MVP VT Plus (Non-Standard) Value Drug List (VT)

Lists prescription medications offered at a $1 or $3 copay for a 30-day supply under most MVP VT Plus (Non-Standard) plans in Vermont; beneficiaries must confirm availability in their specific plan benefit documents and consult prescribers.

Policy Summary

PayerMVP Health Care

PolicyMVP VT Plus (Non-Standard) Value Drug List (VT)

Policy CodePolicy N/A

Change TypeInformational — no material change

Effective Date

Next Review Date

Key ActionProviders and members must review the member's specific benefit documents to determine whether the MVP VT Plus plan they have chosen offers these value drugs at the $1 or $3 copay.

POLICY UPDATE CHANGES

No material changes

Value drug listSummary

MVP VT PlusPlans

$1 or $3Copay levels

Policy summary and scope

Payer: MVP Health Care; Policy title: MVP VT Plus (Non-Standard) Value Drug List (VT); Status: CURRENT. This is an informational list of value drugs offered with most MVP VT Plus (Non-Standard) plans in Vermont. The medications listed are available at a $1 or $3 prescription drug co-pay for a 30-day supply, depending on the specific MVP VT Plus plan in which you are enrolled. The Vermont Value Drug list is subject to change based on decisions by the MVP Pharmacy & Therapeutics Committee. This document is informational only and does not guarantee coverage; members should contact MVP Customer Care or review their plan-specific benefit documents for confirmation.

Listed value drugs and mappings

This brief provides a raw mapping of listed drugs and related notes to show which medications are included on the Vermont Value Drug list and incidental mapping notes. It is for informational purposes only — only a member's specific benefit documents or MVP Customer Care can confirm whether these drugs are available under an individual plan, and prescribers should determine the appropriate medication for each patient.

Listed Drug	Note / Mapping
{"text":"Atenolol","status":""}\|{"text":"To Treat Diabetes = Glipizide; To Prevent Clotting = Clopidogrel","status":""}
{"text":"Clonidine Tab","status":""}\|{"text":"To Treat Diabetes = Glipizide ER; To Prevent Clotting = Jantoven","status":""}
{"text":"Enalapril","status":""}\|{"text":"To Treat Diabetes = Glipizide XL; To Prevent Clotting = Warfarin Sodium","status":""}
{"text":"Enalapril/HCTZ","status":""}\|{"text":"To Treat Diabetes = Glipizide-Metformin; To Prevent Clotting = To Treat Osteoporosis","status":""}
{"text":"Furosemide","status":""}\|{"text":"To Treat Diabetes = Glyburide; To Prevent Clotting = To Treat Osteoporosis","status":""}
{"text":"Hydrochlorothiazide Cap","status":""}\|{"text":"To Treat Diabetes = Glyburide-Metformin; To Prevent Clotting = Alendronate","status":""}
{"text":"Hydrochlorothiazide Tab","status":""}\|{"text":"To Treat Diabetes = Metformin; To Prevent Clotting = To Treat Asthma","status":""}
{"text":"Lisinopril","status":""}\|{"text":"To Treat Diabetes = Metformin ER (generic Glucophage XR); To Prevent Clotting = To Treat Asthma","status":""}
{"text":"Lisinopril/HCTZ","status":""}\|{"text":"To Treat Diabetes = Novolin 70-30; To Prevent Clotting = Montelukast","status":""}
{"text":"Losartan","status":""}\|{"text":"To Treat Diabetes = Novolin N; To Prevent Clotting = QVAR","status":""}
{"text":"Losartan/HCTZ","status":""}\|{"text":"To Treat Diabetes = To Control High Cholesterol; To Prevent Clotting = QVAR; also lists Fenofibrate Tab (48 mg, 145 mg, 160 mg, 54 mg)","status":""}
{"text":"Metoprolol Tartrate","status":""}\|{"text":"To Treat Diabetes = .; To Prevent Clotting = .","status":""}
{"text":"Spironolactone","status":""}\|{"text":"To Treat Diabetes = Fenofibrate Capsules; To Prevent Clotting = .","status":""}
{"text":"Spironolactone/HCTZ","status":""}\|{"text":"To Treat Diabetes = Simvastatin 80mg; To Prevent Clotting = .","status":""}

What providers must do

Documentation Required

Confirm plan-specific availability

Providers and members must review the member's specific benefit documents to determine whether the MVP VT Plus plan they have chosen offers these value drugs at the $1 or $3 copay.

Prior Authorization

Not a guarantee of coverage — verify benefits

This list is informational and not a guarantee of coverage; providers should verify coverage, limitations, and exclusions through plan benefit documents or by contacting MVP Customer Care at 1-800-348-8515 (TTY 1-800-662-1220) prior to prescribing.

1-800-348-8515 (TTY 1-800-662-1220)