Prescription Drugs

If you are an Elderplan FIDA Total Care (Medicare-Medicaid) participant, information about prescription drug coverage can be found here.

Striving to Provide the Best Prescription Drug Coverage in Greater Metropolitan New York

Getting the medication you need can be an expensive proposition. But Elderplan works hard to provide you with affordable prescription drug coverage. Just look at what some of our plans have to offer!

Formularies

Part D Quality Assurance

Drug Exclusions

By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plans. These drugs are not considered Part D drugs and may be referred to as “exclusions” or “non-Part D drugs.” These drugs include:

  • Nonprescription drugs
  • Drugs when used for anorexia, weight loss or weight gain
  • Drugs when used to promote fertility
  • Drugs when used for cosmetic purposes or hair growth
  • Drugs when used for the symptomatic relief of cough or colds
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
  • Drugs when used for the treatment of sexual or erectile dysfunction

In addition, a Medicare Prescription Drug Plan cannot cover a drug that would be covered under Medicare Part A or Part B.

Also, while a Medicare Prescription Drug Plan can cover off-label uses of a prescription drug, we cover the off-label use only in cases where the use is supported by certain reference book citations. Congress specifically listed the reference books that list whether the off-label use would be permitted. These compendia are: (1) American Hospital Formulary Service Drug Information; (2) United States Pharmacopoeia-Drug Information; and (3) the DRUGDEX Information System; and (4) Medscape. If the use is not supported by one of these reference books (known as compendia), then the drug would be considered a non-Part D drug and would not be covered by Elderplan.

Drug Management Programs

Utilization management
For certain formulary drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits to help us to provide quality coverage to our members:

  • Prior Authorization: We require you to get prior authorization for certain drugs. This means that providers will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug. See “Formulary Product Prior Authorization Approval Criteria” below.
  • Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to six tablets per prescription for Imitrex tablets.
  • Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
  • Generic Substitution: When there is a generic version of a brand name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand name drug or writes “DAW” on the prescription.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary. If your drug is subject to one of these additional restrictions or limits and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).

Formulary Prior Authorization Approval Criteria

Certain drugs need authorization from Elderplan prior to dispensing at the pharmacy. Please click on the Prior Authorization Approval List link to see if you meet the criteria to receive authorization for your drug. You can also go to the searchable formulary to see if your drug needs prior authorization. If you have any questions regarding prior authorizations, call our pharmacy benefit manager at 1-866-490-2102 or Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 711).

Drug Utilization Review

We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor prescribing their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems, such as:

  • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Drugs that are inappropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking
  • Drug allergy contraindications
  • Drug dosage errors or duration of drug therapy
  • Clinical abuse and misuse of medications
  • Over-utilization and under-utilization of medications

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Utilization Management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits to help us provide quality coverage to our members:

Getting the medication you need can be an expensive proposition. But Elderplan works hard to provide you with affordable prescription drug coverage. Just look at what some of our plans have to offer!

For certain drugs, Elderplan limits the amount of the drug that Elderplan will cover. For example, Elderplan provides 30 tablets per prescription for Pioglitazone. This may be in addition to a standard one-month or three-month supply. Please check our downloadable formulary or the searchable link posted on our website to see if your drug has a Quantity Limit restriction.

If you have any questions regarding Quantity Limits, call our Pharmacy Benefit Manager (PBM) CVS/caremark at 1-866-490-2102 or Member Services at 1-800-353-3765. The TTY number for the hearing impaired is 711. Member Services is available seven days a week between the hours of 8:00 a.m. and 8:00 p.m.

Elderplan for Medicaid Beneficiaries (HMO SNP)
Elderplan Extra Help (HMO)
Elderplan Plus Long-Term Care (HMO SNP)
Elderplan Advantage for Nursing Home Residents (HMO SNP)

2019 Prior Authorization Approval List: English


Certain drugs need authorization from Elderplan prior to dispensing at the pharmacy. Please click on the Prior Authorization Approval List link to see if you meet the criteria for you to receive authorization for your drug. You can also go to the searchable formulary, to see if your drug needs prior authorization.

If you have any questions regarding prior authorizations, call our pharmacy benefit manager at CVS/caremark at 1-866-490-2102, or the TTY number for the hearing impaired, 711, seven days a week between the hours of 8:00 a.m. and 8:00 p.m.

Elderplan for Medicaid Beneficiaries (HMO SNP)
Elderplan Extra Help (HMO)
Elderplan Plus Long-Term Care (HMO SNP)
Elderplan Advantage for Nursing Home Residents (HMO SNP)

2019 Step Therapy List: English


Step Therapy is a key part of our prior authorization program that allows us to help your doctor provide you with an appropriate and affordable drug treatment. Elderplan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Elderplan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Elderplan will then cover B. Please click on the Step Therapy Approval List to see if your drug requires Step Therapy. You can also go to the searchable formulary to see if your drug requires Step Therapy.

If you have any questions regarding Step Therapy, call our pharmacy benefit manager at CVS/caremark at 1-866-490-2102. The TTY number for the hearing impaired is 711. Member Services is available seven days a week between the hours of 8:00 a.m. and 8:00 p.m.

Drug utilization review

We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor prescribing their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems, such as:

  • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Drugs that are inappropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking
  • Drug allergy contraindications
  • Drug dosage errors or duration of drug therapy
  • Clinical abuse and misuse of medications
  • Over-utilization and under-utilization of medications

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Plan Forms:

The following forms are also available on the Centers for Medicare and Medicaid Services (CMS) website:

Appointment of Representative: English | Español

Out of network policy: In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. See Evidence of Coverage for more information.

Exceptions and Appeals

To view appeals, grievance and coverage determination processes, please review Chapter 9 of the Evidence of Coverage applicable:

Elderplan Part D Transition Process

As a new or continuing member in Elderplan, you may be taking drugs that are not on our Drug List  (formulary) or that are subject to certain utilization management requirements or limitations as described above. Under certain circumstances, Elderplan will allow a temporary applicable month’s supply of a drug that is not on our Drug List or has utilization management requirements or limitations. During the time when you are receiving a temporary supply of a drug, you should talk with your doctor to discuss your options when your temporary supply runs out. After we allow a temporary applicable month’s supply, we generally will not pay for these drugs as part of our transition policy again.

In the case of a drug that you are taking that is not on our formulary, you should talk with your doctor to decide if the alternative drug on our Drug List is right for you or request an exception: English | Español (which is a type of coverage determination) in order to get coverage for the drug. Check the “What is an exception?” section of your Evidence of Coverage to learn more about how to request an exception. You can also contact our Member Services listed below.

The co-pay for a temporary supply will be based on one of our approved formulary tiers. It will also be consistent with cost sharing charged for drugs that are approved under a coverage exception. Co-pays for members who are eligible for “Extra Help” will never exceed the co-pay maximums set by CMS for low-income members.

Please note that our transition policy applies only to those drugs that are “Part D drugs” and that are bought at a network pharmacy. The transition policy cannot be used to buy a non-Part D drug or a drug out of network, unless you qualify for out-of-network access.

 

For any additional information on the transition process, please call Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week. TTY users call 711.

Elderplan will send you a written notice within three (3) business days of the transition fill explaining the following:

  • That the transition supply is temporary and may not be refilled unless a coverage determination is requested and approved
  • Procedures for requesting a coverage determination, including a formulary exception
  • How to work with Elderplan and your doctor to identify appropriate alternative drugs on the Drug List (formulary)
  • Your right to request a coverage determination which includes a formulary exception, the timeframes for handling the coverage determination, and your right to request an appeal

New Elderplan Members

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.

Continuing Elderplan Members

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.

 

Elderplan Members 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.

Sample Part D Transition Letter 
English | Español

Pharmacy Overview

Not only do you get generous benefits, but you can also choose from more than 3,819 network pharmacies. How easy is that? With Elderplan, you can save money on drugs and never have to travel far to fill your prescriptions. Read More

For more general information that is not specific to an individual plan, please view the following links:

  • Medicare Electronic Complaint Form: English | Español
  • Additional information about Extra Help – Best Available Evidence (BAE) Policy: English

With Elderplan you get all the great benefits of Original Medicare plus a lot more! In fact, you enjoy some of the most generous prescription drug benefits in Greater Metropolitan New York. When you’re ready to become a member, you can enroll on this site, or call us at 1-800-353-3765 or TTY for the hearing impaired at 711 to make an appointment or enroll over the phone. Call 8 a.m.–8 p.m., 7 days a week.

Notice: If you enroll in a separate Medicare health plan or prescription drug plan, you will automatically be disenrolled from Elderplan and lose all of your medical and prescription drug benefits with us. It’s important to compare the benefits before signing a contract with a separate plan. Call Elderplan at 1-800-353-3765 (TTY: 711), 8 a.m.–8 p.m., 7 days a week, to speak with a Member Services Representative before you join another Medicare plan.

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