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

Formulary FAQs: Click Here

Downloadable Formulary: 
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Formulary Changes:
English

Formulary FAQs: Click Here

Downloadable Formulary: 
English | Español

Formulary Changes:
English — Coming Soon

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)

2018 Prior Authorization Approval List: English
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)

2018 Step Therapy List: English
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 restrictions, such as prior authorization or step therapy. 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.

You may be able to get a temporary supply (transition fill or supply):

  • Under certain circumstances, Elderplan can offer a temporary 30-day supply (unless prescription is written for less) of a drug that is not on our Drug List or requires prior authorization or step therapy.
  • During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by our plan that is right for you. Or you and your doctor can ask for an exception. After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again.
  • 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 can’t 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 formulary exception or 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 business days of the transition fill explaining the following:

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

Sample Part D Transition Letter 
English | Español

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 but require prior authorization or step therapy (requirement to try a different drug first). Anytime during the first 90 days you are a member, you may be eligible to receive a 30-day transition supply of each drug you are taking when you go to a network pharmacy.
  • If you get a 30-day transition supply, you should talk with your doctor to decide if you should switch to an appropriate alternative drug that is covered on the formulary. After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again.
  • If no appropriate alternative drugs are on the formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to get the drug you are taking for a specified period of time.
  • If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will allow a refill of a prescription until we have provided 91-day and maybe up to a 98-day transition supply, consistent with the dispensing increment (unless the prescription is written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of Elderplan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in Elderplan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Current Elderplan Members

  • As a continuing 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, the drug’s cost sharing will change, or the drug requires prior authorization or step therapy in the upcoming year. If this happens, you should talk with your doctor to decide if you should switch to an appropriate alternative drug that is covered on our formulary. We will provide you with the opportunity to request a formulary exception in advance for the following year.
  • If no appropriate alternative drugs are on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time.
  • If you are still within the first 90 days of your membership, you may be eligible to receive an initial 30-day transition supply of the drug.
  • If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91-day and maybe up to 98-day transition supply, consistent with dispensing increment. We will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of Elderplan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in Elderplan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Current Elderplan Members who enter a long-term care (LTC) facility (level of care change)

  • If you enter a long-term care (LTC) facility from the outpatient (home), hospital or another LTC facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days after you have entered the LTC facility.
  • If you leave the LTC facility or a hospital and return to the outpatient setting, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) within the first seven days following the discharge when you go to a network pharmacy, for each of the drugs that is not on our Drug List or that has coverage restrictions or limits (and the drug is otherwise a “Part D drug”). After the first 30-day supply, we will not pay for these drugs. We will allow a refill of a prescription until we have provided 91-day and maybe up to a 98-day transition supply, consistent with the dispensing increment (unless the prescription is written for fewer days).

Certain drugs need authorization from Elderplan prior to dispensing at the pharmacy. Please click on the Prior Authorization Approval Criteria List link above 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).

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.

Looking for information?

Questions? Call Elderplan today.

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[TTY 711]

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Elderplan is available
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and Monroe counties.