Part D Prescription Drugs
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!
Additional Materials
2013 Formulary
Notice of Formulary Changes
Elderplan Classic Zero Premium (HMO)
All Other Plans
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 to provide quality coverage to our members:
2013 Quantity Limit Approval List
For certain drugs, Elderplan limits the amount of the drug that Elderplan will cover. For example, Elderplan provides 5 tablets per prescription for Anzemet. This may be in addition to a standard one-month or three-month supply. Please click on the Quantity Limit Approval List to see if your drug has a Quantity Limit restriction. You can also go to the searchable formulary to see if your drug has a Quantity Limit restriction. If you have any questions regarding Quantity Limits, call our pharmacy benefit manager at Envision/Rx Options, Inc. at 1-800-361-4542 or Member Services at 1-800-353-3765. The TTY number for the hearing impaired is 1-800-662-1220. Member Services is available seven days a week between the hours of 8:00 a.m. and 8:00 p.m.
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 Envision/Rx Options, Inc. at 1-800-361-4542 or Customer Service at 1-800-353-3765, or the TTY number for the hearing impaired, 1-800-662-1220, seven days a week between the hours of 8:00 a.m. and 8:00 p.m.
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 Envision/Rx Options, Inc. at 1-800-361-4542 or Member Services at 1-800-353-3765. The TTY number for the hearing impaired is 1-800-662-1220. Member Services is available seven days a week between the hours of 8:00am and 8:00 pm.
Medication Therapy Management (MTM) Program
Our MTM program is a FREE program that is offered by Elderplan for members who meet our selected criteria described below. Please note that this program is not considered a benefit.
Under our Medication Therapy Management, or MTM, you will have access to the following free services:
- A telephonic consultation with a pharmacist to review your current prescriptions and over-the-counter medications–the pharmacist will call you to talk about any medication-related issues you may be experiencing and to create a specific medication action plan, or MAP, that you can share with your doctor.
- Ongoing comprehensive medication review–Elderplan, in consultation with your doctor, will review your medications on a regular basis to ensure that your medication action plan remains current.
Advantages of the MTM Program include:
- Identify and reduce the chance for medication errors
- More information about your current medication therapy
- Opportunity to save money by reducing duplicative therapy and offering affordable formulary alternative availability if applicable
- Identifying and educating you on the side effects of the drugs you are taking and discussing ways to reduce those effects.
For more information about the MTM Program and to schedule your free medication review with a pharmacist, please call the number on your MTM welcome letter. An MTM welcome letter is sent to you if you qualify for the program. You can also call Elderplan Member Services at 800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 1-800-662-1220) for additional information.
What is the medication therapy management (MTM) program?
The MTM program is designed to help our Elderplan members deal with multiple medications and illnesses. This program is another way to help you get the safest, most effective and affordable prescription drugs. Our staff works with individual members and their health care providers to be a source of information and support for medication management.
How does it work?
Once you are selected for MTM program, you will receive a welcome letter from our MTM vendor and information about MTM. Our MTM vendor will contact you to schedule a telephone consultation with a pharmacist. Pharmacist will conduct a comprehensive medication review to identify any potential medication related issues. If any medication issue is identified during the telephonic consultation with a pharmacist, we will discuss it with your provider. Participation in this program is voluntary. You can contact Elderplan Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 1-800-662-1220) to opt-out of the program.
How can the program help the participant?
Our licensed pharmacists will assist you by being a source of knowledge about prescription and over-the-counter drugs. We can answer questions you may have about your medications and discuss potential drug therapies with your providers. Overall, our goal is to make sure you are getting and taking the types of medication that are right for you.
Who is eligible for the program?
Eligible participants are those members with Medicare Part D prescription coverage who take at least 8 (eight) Part D drugs and spend more than $750 per quarter on Part D medications. Participants of the program also have at least 3 of the following conditions (condition overviews are provided on the other page):
- Diabetes
- Hyperlipidemia (high cholesterol)
- Hypertension (high blood pressure)
- Osteoporosis
You are not required to participate in this program. If you do not wish to do so, you can contact Elderplan Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 1-800-662-1220) to opt-out.
How long does the program last?
The program runs from the time that the member meets eligibility requirements until the end of the calendar year. You may be re-enrolled in the program the following January if you want to participate in the program, and you continue to meet the requirements for the new contract year. Rev. 11.29.10. ef
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 1-800-361-4542 or Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week (TTY: 1-800-662-1220).
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.
2013 Plan Forms
- Request for Medicare Prescription Drug Coverage Determination Form English/Spanish
- Part D Coverage Determination for Elderplan Members Only via secure Web form.
- Part D Coverage Re-determination for Elderplan Members Only via secure Web form.
- Appointment of Representative/Nombramiento de Representante
- Pharmacy Overview
- Part D Quality Assurance
- Transition Policy
- Low Income Premiums
- Information Update Form
- Member Reimbursement Form
- Tier Exception Request Form English/Spanish
- Medication Exception Request Form For Non-Formulary Drug, Quantity Limit and Step Therapy English/Spanish
- Part B vs Part D Prior Authorization List
- Prior Authorization Request Form English/Spanish
- Prior Authorization Request Form: Aranesp, Epogen and Procrit English/Spanish
The following forms are also available on the Centers for Medicare and Medicaid Services (CMS) website:
Appointment of Representative:
http://www.cms.gov/cmsforms/downloads/cms1696.pdf
Coverage Determination:
http://www.cms.gov/MedPrescriptDrugApplGriev/Downloads/ModelCoverageDeterminationRequestForm.pdf
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.
2013 Exceptions and Appeals
To view appeals, grievance and coverage determination processes, please review Chapter 9 of the Evidence of Coverage applicable (refer to Chapter 8 for Elderplan Plus Long-Term Care (HMO SNP) EOC):
Elderplan for Medicaid Beneficiaries (HMO SNP)
Elderplan Advantage for Nursing Home Residents (HMO SNP)
Elderplan Classic Zero Premium (HMO)
Elderplan Plus Long-Term Care (HMO SNP)
Elderplan Medicaid Advantage (HMO SNP)
Elderplan Extra Help (HMO)
For more general information that is not specific to an individual plan, please view the following links:
- Coverage Determination
- Appeals Process
- Grievance Process
- Medicare Electronic Complaint Form
- Medicare Ombudsman
- Additional information about Extra Help – Best Available Evidence (BAE) Policy
For more general information that is not specific to an individual plan, please view the following links:
- Coverage Determination
- Appeals Process
- Grievance Process
- Medicare Electronic Complaint Form
- Medicare Ombudsman
- Additional information about Extra Help – Best Available Evidence (BAE) Policy
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 1-866-360-1934 or TTY for the hearing impaired at 1-800-662-1220 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 1-800-662-1220), 8 a.m.–8 p.m., 7 days a week, to speak with a Member Services Representative before you join another Medicare plan.
