How Your Pharmacy Benefit Works
Your Elderplan Advantage for Nursing Home Residents (HMO-POS I-SNP) pharmacy benefit comes with a $22.40 Part D premium and a $700 yearly drug deductible
The deductible applies to all covered drugs except covered insulin products and most adult Part D vaccines. You pay the lowest cost when you fill covered drugs at a network pharmacy or through mail order. If you use a pharmacy outside the network without an approved exception, you will generally pay the full cost out of pocket.
Types of Network Pharmacies
| Network Pharmacy | Mail-Order Pharmacy (CVS Caremark) |
|---|---|
| Any pharmacy with a contract with the plan to provide your covered drugs. You may go to any of our network pharmacies. | Get up to a 90-day supply of maintenance drugs delivered to you. Most orders arrive in 5–7 business days. Drugs marked “NM” on the Drug List are not available by mail order. |
How to get started with mail-order:
- Log in to your account at Caremark.com.
- By phone: Call CVS/Caremark at 1-866-490-2102 (TTY: 711), available 24 hours a day, 7 days a week.
Important Things to Know
- If your mail-order is delayed: If your provider instructs you to begin a medication right away and your mail-order has not yet arrived, you may get a 30-day supply from a local network pharmacy. You will be responsible for the applicable cost-sharing for both the mail-order prescription and the local fill.
- Drugs marked “NM”: Some drugs in the plan’s Drug List are marked “NM” and are not available through mail-order. You will need to fill those at a network retail pharmacy or, if you live in an LTC facility, through your facility’s pharmacy.
- Automatic refills: You can sign up for the Automatic Refill Program. The pharmacy will contact you before shipping each refill to confirm you still need the medication. To opt in or out, log in to your Caremark.com account or call CVS/Caremark at 1-866-490-2102 (TTY: 711).
- Automatic delivery of new prescriptions: If you have used mail-order before, or have opted in to automatic delivery, the pharmacy will automatically fill and ship new prescriptions it gets from your doctor. To opt in or out at any time, log in to your Caremark.com account or call CVS/Caremark at 1-866-490-2102 (TTY: 711).
- Unwanted deliveries: If you receive a prescription automatically that you did not want and were not contacted before it shipped, you may be eligible for a refund. Call CVS/Caremark to request one.
Living in a Long-Term Care Facility
- Your facility’s pharmacy must be in our network. Check the Provider and Pharmacy Directory— or call Member Services. If your LTC facility’s pharmacy is not in our network, we will help you find a solution so you can continue to receive your Part D drugs.
- 31-day supply per fill. LTC pharmacies fill prescriptions in up to 31-day supplies, with the same cost-sharing per fill as standard retail.
- Hospital or skilled nursing stays. If you are admitted to a hospital or to a skilled nursing facility for a stay covered by your plan, your plan generally covers your prescription drugs during the stay. Once you leave, regular Part D coverage rules apply again.
- Drugs not on the Drug List. If you are a resident in an LTC facility and need a drug that is not on our Drug List or has a coverage rule, you may be eligible for a temporary or emergency supply. Call Member Services for help.
Important Reminders About Your Pharmacy Benefit
Things to keep in mind at the pharmacy:
- Always show your Elderplan Member ID card. Show your Elderplan Member ID card — not your red, white, and blue Medicare card — every time you fill a prescription. Show your Medicaid card too, since you have both Medicare and Medicaid.
- Save money with 90-day supplies. For medications you take regularly, ask for a 90-day supply through mail-order or a retail pharmacy in your network that offers extended supplies. Tier 2, 3, and 4 drugs cost less per supply through mail-order than at retail.
- LTC residents: confirm your facility’s pharmacy is in-network. If you live in a nursing home, assisted living facility, or other long-term care setting, check whether the facility’s pharmacy is in our network at elderplan.org or by calling Member Services. We will help if it is not.
- Always call ahead before traveling. Before traveling, check with Member Services or look up network pharmacies at your destination. If possible, order your prescriptions by mail in advance so you have enough supplies while you are away.
- Coverage is limited to the United States and its territories. Your plan does not cover prescriptions purchased outside the United States or its territories — even in an emergency.