Review the Elderplan Provider Manual here.
Specialist Referral Request Form
Physician’s Order Form for CDPAS
Non-Preferred Part B Drug Request Forms:
- Granix, Leukine, Neupogen, Nivestym, Releuko
- Udenyca, Nyvepria, Ziextenzo, Fylnetra, Rolvedon, Stimufend
- Herzuma, Ogivri, Ontruzant, Herceptin, Herceptin, Hylecta
Specialty Exceptions Policies:
100-Day Supply Prescriber Notice
Request for Part D Coverage Determination
Request for Redetermination of Medicare Prescription Drug Denial
Member Part D Reimbursement Form
Medicare Prescription Payment Plan
Elderplan has partnered with Zelis Healthcare to offer you the option to select EFT to deposit funds directly into your bank account. To receive your payments electronically, with no fees, please sign up for EFT (https://elderplan.epayment.center) and click on “Sign Up Now”.
Providers may choose to use other payment options offered by Zelis, such as their ACH+ or VCC payment options, which come with a fee. These options enable providers to utilize an online Zelis portal and streamline payments from multiple payors. To register click here: (https://www.zelis.com/providers/provider-enrollment/)
