Formulary FAQs

How do I use the searchable formulary?

Enter the first few letters of the drug you wish to add and then select the drug from the drop-down menu.

What is the Elderplan formulary?

A formulary is a list of covered drugs selected by Elderplan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Elderplan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Elderplan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

What are generic drugs?

Elderplan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Can the formulary change?

Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The searchable formulary is updated in real time to reflect current coverage.

In the event that the plan makes a mid-year non-maintenance formulary change, we will notify you of the change via mail, so you can update your existing printed formulary. The mailing will include specific information on the non-maintenance formulary change and will be sent to you at least 60 days prior to the date the change becomes effective.

What if my drug is not on the formulary?

If your drug is not included in this formulary, you should first contact Elderplan Member Services and ask if your drug is covered. If you learn that Elderplan does not cover your drug, you have two options:

You can ask Elderplan Member Services for a list of similar drugs that are covered by Elderplan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Elderplan.

You can ask Elderplan to make an exception and cover your drug. See below for information about how to request an exception.

NOTE: Due to a change in Medicare, most Medicare Drug Plans no longer cover erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra and Caverject. For more information, please contact CVS/Caremark at 1-866-490-2102; TTY 711; P.O. Box 52000, MC109, Phoenix, AZ 85072-2000; Fax: 1-855-633-7673; 7 days a week, 24 hours a day.

How do I request an exception to Elderplan’s formulary?

The first step in requesting an exception is for you to ask your prescribing doctor to contact Elderplan’s Pharmacy Benefit Manager, For more information, please contact CVS/Caremark at 1-866-490-2102; TTY 711; P.O. Box 52000, MC109, Phoenix, AZ 85072-2000; Fax: 1-855-633-7673; 7 days a week, 24 hours a day.

You may need to fill out an exception request form, which can be located in the Find a Form section.

You can ask Elderplan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Elderplan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred Brand tier, you can ask us to cover it at the cost sharing amount that applies to drugs in the preferred Brand tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Elderplan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage determination for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our determination within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a determination. If your request to expedite is granted, we must give you a determination no later than 24 hours after we get your prescribing physician’s supporting statement.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new member in Elderplan, you may currently be taking drugs that are not on the Elderplan formulary or are on the formulary with utilization management requirements or limitations. In such cases, anytime during the first 90 days as a new member, you may be eligible to receive up to a 30-day transition supply of the drug when you go to a network pharmacy.

If you receive a 30-day transition supply, you should talk with your doctor to request a coverage determination for the drug, before finishing the transition supply. Your doctor will have to either address the drug’s utilization management criteria or switch to an appropriate alternative drug that is covered on the formulary. If no appropriate alternative drugs are on the formulary, you or your doctor can request a formulary exception. If the coverage determination is approved, you will be able to receive the drug you are taking for a specified period of time.

As a continuing Elderplan member in our plan from year to year, you will receive an Annual Notice of Change (ANOC) by September 30. You may notice that a formulary drug you currently take will not be on the new formulary, or the drug will have new utilization management rules in the upcoming year. If this happens, you should talk with your doctor to request a coverage determination. Your doctor will have to either address the drug’s utilization management criteria or switch to an appropriate alternative drug that is covered on the formulary.

If no appropriate alternative drugs are on our formulary, you or your doctor can request a formulary exception. We will provide you with the opportunity to request a formulary exception in advance for the following year. If the coverage determination is approved, you will be able to obtain the drug you are taking for a specified period of time.

For continuing members subject to a negative formulary change at the beginning of the new plan year, you may be eligible to receive up to a 30-day transition during the first 90 days, if your drug look-back history determines transition fill eligibility. A negative formulary change is when a part D drug has new utilization management rules or one that is no longer on the formulary beginning of the new plan year.

For new and continuing members, we will allow multiple fills to provide up to a maximum of a 30-day supply if your prescription is written for less. After we allow a (temporary) transition supply, we generally will not pay for these drugs as part of our transition policy again.

What if I am a member residing in a Long-Term Care Facility?

As a new or continuing Elderplan member in a long-term care facility, we will provide up to a 31-day supply during your 90-day transition window. In the event a prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply. If you are past the transition window, you may also be able to receive an emergency supply of up to 31 days (unless you have a prescription for fewer days). In certain circumstances such as a level of care changes, you may also be eligible for a transition supply. A transition supply for oral brand solids are limited to 14-day fills with exceptions as required by CMS guidance. After we allow a (temporary) transition supply, we generally will not pay for these drugs as part of our transition policy again

What drugs are covered through mail order?

For certain kinds of drugs, you can use the plan’s network mail-order services. Mail-order drugs are drugs that you take on a regular basis for a chronic or long-term medical condition. To get order forms and information about filling your prescriptions by mail, please contact Member Services or visit the CVS/Caremark Home Delivery Service website: English | Español.

What is a comprehensive formulary?

A Comprehensive Formulary is an entire list of Part D drugs covered by Elderplan in consultation with a team of health care providers believed to be a necessary part of a quality treatment program. Elderplan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Elderplan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your evidence of coverage.

For more information

For more detailed information about your Elderplan prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Elderplan, please call Member Services at 1-800-353-3765, seven days a week, between the hours of 8 a.m. to 8 p.m. TTY/TDD users should call 711.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit Medicare website: EnglishEspañol.

Questions? Call Elderplan today.

1-866-360-1934

[TTY: 711]

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Elderplan is available
in the 5 boroughs of NYC,
Nassau, Suffolk, Westchester,
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Dutchess and Orange counties.

Questions? Call Elderplan today.

1-866-360-1934

[TTY: 711]

for the hearing impaired

Hours of Operation:
8 a.m. to 8 p.m., 7 days a week

Elderplan is available
in the 5 boroughs of NYC,
Nassau, Suffolk, Westchester,
Rockland, Putnam, Monroe,
Dutchess and Orange counties.

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