Member FAQ

Most of the time, your benefits will go into effect the first day of the month immediately following the month you joined. For example, if you join in March, your Elderplan benefits will start April 1.

To verify your enrollment effective date, please call Member Services at 1-800-353-3765, or TTY: 711, available seven days a week, between the hours of 8:00 a.m. and 8:00 p.m.

You can bring your welcome letter as proof of insurance to your doctor appointments until you get your member card from us. This letter is also proof of your prescription drug coverage. You should show this letter at the pharmacy until you get your member card from us.

Or you can call Member Services! We can help your doctor confirm your benefits if you need medical care and your Elderplan coverage has started, but your card has not arrived.

Elderplan has a contract with Medicare to provide you with all of your health benefits. That means you should use Elderplan’s member card for your doctor visits, hospitalization, prescriptions and other medical services. Don’t worry, you are still part of Medicare, but now you receive expanded benefits with Elderplan.

DO NOT USE YOUR MEDICARE CARD. Put your Medicare card in a safe place where you can find it. Do not throw it away.

From now on, your Elderplan member card is the card you need.

Contact Member Services if you did not get an Elderplan member card or if you need a replacement card.

If you have Medicare and Medicaid, you should show your Elderplan member ID card along with your Medicaid card any time you visit a doctor, hospital, pharmacy, lab or other service provider. This will ensure that all providers know how to properly bill.

Primary Care Physicians, or PCPs, provide a full range of basic health services. PCPs can be:

• General practitioners
• Family practice physicians
• Internists
• On occasion, obstetrician/gynecologists
• Pediatricians

When you become a member of Elderplan, you must choose a plan provider to be your PCP. Your PCP is a physician who meets state requirements and is trained to give you basic medical care. You will get your routine or basic care from your PCP. Your PCP will also coordinate the rest of the covered services you get as a member of Elderplan.

If you need to search for a PCP or other provider, call Member Services to request an updated list or check our online provider locator.

You may change your PCP to another doctor within the Elderplan network at any time. There are two ways you can do this:

• Call the Member Services Department and speak with a representative.
• Mail your request for a new PCP to:

Elderplan Member Services
55 Water Street 46th Floor, Suite 202
New York, NY 10041

Either way, once your request is processed, a new Elderplan member card listing the name of your new PCP will be sent to you.

• You do not need a referral from your Primary Care Physician (PCP) in order to see a specialist.
• Sometimes you will need prior authorization from Elderplan before receiving certain types of care. In this case, your PCP will contact Elderplan and let you know if and when approval is given.

• Contact your PCP.
• Elderplan will need to authorize any request for a second opinion. Your PCP will contact Elderplan for you.
• You must pay any applicable co-payment for a specialist visit when you go for your second opinion. Be sure to pay it before you leave the specialist’s office.

Elderplan will cover specialists, dentists, emergency care and urgently needed care from an out-of-network provider; this does not require prior authorization. If you are using the plan’s coverage for your medical services that Medicare requires our plan to cover, and the providers in our network cannot provide this care , you can get this care from an out-of-network provider. For example, kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area, are covered. You must contact us to get authorization prior to seeking this care. Please contact Member Services to obtain any necessary prior authorizations.

A Care Manager is your dedicated go-to person, committed to helping you stay healthy. They will be there to support and guide you by coordinating your care and arranging your medical visits, as well as transportation, to get you there. They serve as the point person between you, your doctors, and other healthcare professionals to develop your care plan and ensure you receive the services you need, allowing you to remain safely at home.

No. As an Elderplan member, you already have this coverage, so there’s no need to sign up for a separate Medicare Prescription Drug Plan. That’s because Elderplan is a Medicare Advantage Part D (MA-PD) plan, which includes the Medicare Prescription Drug Plan. That means we contract with Medicare to provide both comprehensive health care coverage and affordable prescription coverage in one easy plan. So 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. So don’t listen to others who say you need a separate prescription drug plan. You’re covered!

Please Note: If you sign up for a separate prescription drug plan, you will automatically be disenrolled from Elderplan and will lose not only your generous prescription drug coverage, but all of your great Elderplan benefits.

No. Generally, benefits are only available at contracted network pharmacies. Normally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Whenever possible, before you fill your prescriptions at an out-of-network pharmacy, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription.

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what members pay for their drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $5,030. After a member enters the coverage gap, they pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until their costs total $8,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. After a member’s yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,100 they pay the greater of: 5% of the cost, or $4.50 copay for generic (including brand drugs treated as generic) and a $11.20 copayment for all other drugs.

Elderplan for Medicaid Beneficiaries (HMO SNP) and Elderplan Plus Long-Term Care (HMO SNP) members won’t have to worry about the coverage gap. And, because Low Income Subsidy (LIS) also known as Extra Help pays for your prescriptions throughout the coverage gap, you only pay nominal prescription drug co-payments no matter how many medications you take.

With Elderplan Advantage for Nursing Home Residents (HMO SNP) and Elderplan Extra Help (HMO), there is a coverage gap unless you are receiving Low Income Subsidy (LIS) also known as Extra Help

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE. TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week. Or call the Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778, or your State Medicaid Office.

You can check your balance through the OTC Member Portal.

You can also download the OTC Network Mobile app to check your balance. It is also a fast and convenient way to check your transaction activity and discover eligible items.

You can also call our Member Services line at 1-800-353-3765 (TTY:711) 8 a.m. to 8 p.m., 7 days a week for assistance.

No. Beginning January 1, 2024, your OTC card will be mailed preactivated.

No. Your OTC card does not require a PIN number to use in stores. Simply swipe your OTC card at checkout, select “credit,” and complete your transaction.

Traditional Over-the-Counter (OTC) refers to the standard benefit and allows you to purchase items that you can buy without a prescription and health-related things like toothpaste, vitamins, and bandages.

OTC+ Grocery & Meals is an extended benefit offered to eligible Elderplan members. Eligible members can use their OTC card to buy over-the-counter items, plus healthy groceries and home-delivered meals. Check your eligibility.

For the most up to date list of eligible items log into the OTC Member Portal. The OTC Network Mobile app is also a useful way to discover eligible items.

Participating retailers include CVS, Walgreen, Rite Aid, Walmart, Dollar General, and Family Dollar.

You can go to the OTC Member Portal, log in with your 19-digit OTC card number, navigate to the Retailers tab, select from the dropdown menu and narrow down your search to specific locations.

All laboratory services must be furnished by an Elderplan contracting laboratory. If your Primary Care Physician has referred you for lab services and you receive a bill, DO NOT PAY IT.
Send it to:
Elderplan Claims Department
P.O. Box 73111
Newnan, GA 30271-3111

If you continue to receive bills or other letters regarding the laboratory service, please contact Member Services immediately.

If you have a claim denied, you may ask Elderplan to reconsider its determination. This is called an “appeal” or “request for reconsideration.”

If you need help in filing your appeal, please call Member Services. When we receive your request for an appeal, we will distribute it to different people other than those who made the determination to deny your claim. This helps ensure your request gets fair reconsideration.

Urgent care is needed when your medical condition does not place you in serious jeopardy but could get worse and care is immediately needed. If you are in the Elderplan service area and need urgent care, call your Primary Care Physician (PCP).

Urgent care may be provided when you are outside the Elderplan service area. You may visit a walk-in clinic or doctor’s office for urgent care. If you are admitted to the hospital within one day for the same condition, you do not pay any cost sharing for the urgent care visit.

Emergency care is needed when the onset of your condition is sudden and severe, and the absence of immediate medical attention could place you in serious jeopardy. You may go to any emergency room if you reasonably believe you need emergency care. There is a co-payment or co-insurance for the visit, but you do not pay this amount if you are admitted to the hospital within one day for the same condition.

Urgent care is only covered in the USA. Emergency care is covered worldwide.

While you’re in the hospital, Elderplan pays all your prescription drug costs. Plus, we’ll pay for small amounts of prescription drugs to “carry you over” until you get home and start using your personal supply again.

Maybe. Doctors can only visit patients in hospitals where they are on staff or have what are called “visiting privileges.”

Usually, this is not a problem because Elderplan must approve your planned hospitalizations before you receive treatment.

If there is an emergency, and you are taken to a hospital outside our network or where your doctor can’t visit you, you can contact your Primary Care Physician, and he or she can help coordinate your care.

Providers should only bill Elderplan for the cost of your covered services and items. If a provider sends you a bill instead of sending it to Elderplan, you can send it to us to pay. You should not pay the bill yourself. But if you do, Elderplan may pay you back.

If you have any questions, please call:

Elderplan Member Services
1-800-353-3765 (TTY: 711)
8 a.m. to 8 p.m., 7 days a week

The call is free.

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from Elderplan.

During a declared disaster, we will allow you to get care from out-of-network providers at no cost to you. If you cannot use a network pharmacy during a declared disaster, you will be able to fill your prescription drugs at an out-of-network pharmacy.

If Elderplan leaves the Medicare program, by contract termination, or is no longer available in your area because of a service area reduction, we will provide you with a termination notice or plan change notice, well in advance. This notice will provide information about Medicare coverage options available to you because of the plan change, including guaranteed Medigap rights.

Whether leaving the plan is your choice or not, you can find more information about your Medicare choices after you leave and the rules that apply in the Evidence of Coverage.