What is VIVIO?
VIVIO Health Inc. (VIVIO) partners with self-insured Plan Sponsors to manage the benefits administration of Specialty Medications. By carving out these benefits from PBMs and/or Health Plans, VIVIO becomes the primary payor for medications on the Plan’s Specialty Drug List.
VIVIO is independent and does not own any healthcare providers or pharmacies, ensuring unbiased service and support.
Key Benefits of VIVIO
Eliminates conflicts of interest common in the PBM/Insurance industry.
Ensures transparency and fair pricing using Open Market rates.
Operates on a flat PMPM fee, passing all savings directly to Plan Sponsors and members.
Key Benefits of VIVIO
Eliminates conflicts of interest common in the PBM/Insurance industry.
Ensures transparency and fair pricing using Open Market rates.
Operates on a flat PMPM fee, passing all savings directly to Plan Sponsors and members.
How Do Providers Work with VIVIO?
Self-Administered Medications
Pharmacies receive a rejection from the PBM if they attempt to fill a carved-out medication.
VIVIO performs a therapy review and provides authorization for specific medications.
Concierge Support:
VIVIO's team helps members and providers connect with appropriate pharmacies.
Interested pharmacies can join the VIVIO Pharmacy Network by contacting: [email protected].
No Fees: VIVIO charges no DIR or other fees to participating pharmacies.
Medical Specialty Drug Benefit
Professionally Administered Medications
A.
Therapy Review & Authorization
Required for all specialty medications.
B.
Medication Supply Options:
Clearbag: Supplied through the Provider’s own pharmacy.
Whitebag: Supplied through VIVIO’s network pharmacies.
Coordination is available via the Concierge Team.
C.
Buy and Bill Option:
Providers may submit claims with prior approval from VIVIO.
Reimbursement:
Medications: 105% of the Medicare ASP Drug Pricing rate at the time of service.
Administration Codes: The lesser of billed charges or VIVIO’s fee schedule.
Participating in VIVIO’s Any Willing
Provider Medical Specialty Drug Network
Steps to Participate
- Submit a current W-9 Form to [email protected] or include it with your first claim.
- Sign up for electronic payments via the ACH Payment Form.
Submitting Claims
Use CMS 1500 or UB04 forms.
Send via:
Fax: 1.888.677.6754 (Attn: Claims Department) // Secure Email: [email protected]
Include the NDC:
CMS 1500 claims: Box 24 // UB04 claims: Box 43
Please submit claims in a timely manner to ensure prompt processing.
Processing Timeline:
Clean claims: Paid within 45 days via ACH payment.
Incomplete claims or those missing documentation may require additional processing time.
Important Notes
Member responsibility (e.g., deductibles, copays, and coinsurance) must be collected appropriately.
Providers cannot “balance bill” Members for differences beyond Member responsibility.
Members must have active coverage at the time of service for claims to be honored.
If a specialty medication is not listed on the Medicare Fee Schedule, please reach out to [email protected] prior to dispensing or administering it.
