How Your Pharmacy Benefit Works
What to Know Before You Go to the Pharmacy
Your Elderplan Select (HMO-POS I-SNP/IE-SNP) pharmacy benefit includes a $0 Part D premium and a $350 deductible that applies only to Tier 4 and Tier 5 drugs when filled at a network pharmacy or through a mail-order service. 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
Your plan works with several types of pharmacies. Understanding each helps you find the right option for your medications.
| Standard Retail Pharmacy | Long-Term Care (LTC) Pharmacy | Mail-Order Pharmacy |
|---|---|---|
| Any retail pharmacy with a contract with your Elderplan Select plan. When you fill a covered prescription at a network pharmacy, you pay only your applicable cost-sharing — not the full price of the drug. | If you live in a long-term care (LTC) facility such as a nursing home, you usually get your prescriptions through the facility’s pharmacy. The facility’s pharmacy must be part of our network. | Through CVS/Caremark, you can get up to a 90-day supply of maintenance drugs delivered. Mail-order is best for medications you take regularly for a chronic or long-term condition. Most orders arrive within 5–7 business days. |
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 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 at elderplan.org to confirm. 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.