How Your Prescription Drug Benefit Works

What’s Covered and What You May Pay

Your plan covers Medicare Part D prescription drugs when they are filled at an in-network pharmacy or through the plan’s mail-order service. Because you also have Medicaid and qualify for Extra Help, you may be eligible for full premium subsidy so your Part D Premium and Part D Deductible is $0.

Your Prescription Drug Benefit at a Glance

Monthly plan premium: $0
The plan’s monthly Part D premium is $0
Part D deductible: $700
If you are a dual-eligible member with full Extra Help benefits, your Part D deductible is covered on your behalf.

Most members pay $0 to $14.40 per prescription
Your actual cost depends on your Extra Help level.
Insulin cap: $35
The maximum you will pay for a one-month supply of each covered insulin product — even if you haven’t paid your deductible.

Catastrophic Coverage kicks in at $2,400. Once your out-of-pocket drug costs reach $2,400 for the year, you pay $0 for covered Part D drugs for the rest of the calendar year. The Coverage Gap (“donut hole”) no longer exists in Medicare Part D.

Extra Help is automatic for you. Because you have both Medicare and Medicaid, you automatically qualify for Extra Help (also called the Low-Income Subsidy, or LIS). A separate document called the LIS Rider shows the exact amounts that apply to your Coverage. If you don’t have your LIS Rider, call Member Services at 1-877-891-6447 (TTY: 711).

Your Costs During Each Payment Stage

Your Part D drug benefit moves through three payment stages in a calendar year. The stage you are in affects what you pay at the pharmacy.

Stage	What You Pay
Stage 1 — Yearly Deductible	Most members with Extra Help skip this stage. Without Extra Help, you pay the full cost of your drugs until you reach $700. Insulin and most adult Part D vaccines are not subject to the deductible.
Stage 2 — Initial Coverage	You pay your cost-share for each prescription. With Extra Help, you pay $0, $1.65, or $5.80 for generic drugs, and $0, $5.00, or $14.40 for all other drugs — or 25% of the cost, depending on your Extra Help level. You stay in this stage until your out-of-pocket costs reach $2,400.
Stage 3 — Catastrophic Coverage	You pay $0 for covered Part D drugs for the rest of the calendar year.

How to Use Your Prescription Drug Benefit

Make sure your drug is covered. Your plan’s List of Covered Drugs — also called the Drug List or Formulary — shows which drugs are covered and whether any coverage rules apply (like prior authorization, step therapy, or quantity limits). Use the Search for a Prescription Drug tool or call Member Services.
Choose a pharmacy in-network. In most cases, your prescriptions are only covered when filled at an in-network pharmacy. Use the Find a Pharmacy tool to locate one near you.
Show your Elderplan Member ID Card. Bring your Elderplan Member ID card — not your red, white, and blue Medicare card — every time you fill a prescription.
Ask about 90-day supplies for maintenance drugs. For medications you take regularly, ask your pharmacist about a 90-day supply through mail order or at a retail pharmacy in the network that offers extended supplies.
Check your Part D Explanation of Benefits (EOB). Each month you fill a prescription, we send you an EOB showing what you and the plan paid, and which payment stage you are in.

What If Your Drug Isn’t on the Drug List?

If your drug isn’t on the Drug List or has a coverage rule you’d like waived, you have options.

Temporary supply for new members. If you’re new to the plan and the drug you’ve been taking is no longer covered or is now restricted, we’ll cover a temporary 30-day supply during your first 90 days of membership. This gives you time to talk with your doctor about the change. You must fill the prescription at a network pharmacy.

Ask for an exception. You and your doctor can ask the plan to make an exception to cover a drug that isn’t on the Drug List, or to waive a restriction like prior authorization, step therapy, or a quantity limit. Your doctor will need to explain the medical reasons for the request. We’ll give you an answer within 72 hours for a standard request or within 24 hours for a fast (expedited) request if waiting could seriously affect your health.

Change to another covered drug. Your doctor may be able to prescribe a similar drug that’s on the Drug List. Your pharmacist or Member Services can help identify covered alternatives.

Learn more. Visit the Getting Approval for Your Medications page for step-by-step instructions on how to request an exception or coverage determination.

Drugs Covered Through Medicaid Instead of Part D

Some drug categories are excluded from Medicare Part D coverage by law, but are available through the New York State Medicaid Pharmacy Program. Examples include certain over-the-counter medications covered by Medicaid but not Part D. For information, visit health.ny.gov/health_care/medicaid/program/pharmacy.htm or call the New York State Medicaid Program at 1-800-541-2831, Monday–Friday 8 a.m.–8 p.m., Saturday 9 a.m.–1 p.m.

Questions About Your Prescription Drug Benefit?

CVS Caremark mail-order and Part D coverage decisions: 1-866-490-2102 (TTY: 711), 24 hours a day, 7 days a week
Real-Time Benefit Tool: Visit Caremark.com to look up your drug’s Coverage and estimated cost before you fill a prescription
Member Services: 1-877-891-6447 (TTY: 711), 8 a.m.–8 p.m., 7 days a week

Important Reminders About Your Prescription Drug Benefit

Always show your Elderplan Member ID card. Show your Elderplan Member ID — not your red, white, and blue Medicare card — every time you fill a prescription.
Lost, damaged, or stolen card? Call Member Services at 1-877-891-6447 (TTY: 711), and we will send you a replacement.
Your cost depends on your Extra Help level. Most members with Extra Help pay between $0 and $14.40 per prescription. Your LIS Rider shows the specific amounts that apply to your Coverage.
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 the network that offers extended supplies.
Insulin is capped at $35. You will never pay more than $35 for a one-month supply of each covered insulin product — even if you haven’t paid your deductible.
Call ahead before traveling. Before traveling, check with Member Services or look up network pharmacies at your destination.
Some drugs require extra steps. A small number of medications require prior authorization, step therapy, or have quantity limits. You have the right to request a formulary or tiering exception.
The Drug List can change during the year. Most changes take effect on January 1, but some can take effect mid-year. If a drug you take is affected, we’ll send you advance notice and explain your options.