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 60 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 60-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.

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 the following address:
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

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, CVS/caremark. CVS/caremark’s address is P.O. Box 52000 MC109 Phoenix, AZ 85072-2000. CVS/caremark’s fax number is 1-855-633-7673. CVS/caremark’s phone number is 1-866-490-2102, seven days a week, 24 hours a day. TTY users should call 1-866-490-2102. 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 or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary, but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

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 our plan. 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 our plan, 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.

What if I am an existing member in a plan with “Level of Care” changes?

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 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 of membership in our plan. If you need a drug that is not on our formulary or if your ability to get drugs is limited, but you are past the first 90 days of membership in our plan, 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.

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 formulary 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.

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.

1-800-353-3765

[TTY 711]

for the hearing impaired

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

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

Questions? Call Elderplan today.

1-800-353-3765

[TTY 711]

for the hearing impaired

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

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

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