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Frequently Asked Questions
What do drug plans cover?
Medicare drug coverage (Part D) is extra coverage people with Medicare can choose to help lower costs of prescription drugs. Medicare-approved private plans offer this coverage.
All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes, like drugs to treat cancer, HIV/AIDS, or depression. A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary.
How do drug plans work?
All plans must cover a wide range of drugs that people with Medicare take to help make sure that people with different medical conditions can get the prescription drugs they need.
What are Drug lists (formularies)
A plan’s list of covered drugs is called a “formulary.” A plan’s drug list can include both brand-name drugs and generic drugs, as well as original biological products and biosimilars. Each drug list includes at least 2 drugs in the most commonly prescribed categories and classes, but plans can choose which drugs they’ll offer.
All plans must include most drugs in certain protected classes on their drug list. The protected classes include:
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Cancer drugs
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HIV/AIDS drugs
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Antidepressants
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Antipsychotics
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Anticonvulsants
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Immunosuppressants for organ transplants
If Elite Health Plan’s formulary does not include a specific drug, (However, in most cases, a similar drug should be available); then If you or your prescriber believe none of the drugs on Elite Health Plan’s drug list will work for your condition, you can ask for an exception.
An exception is when a drug plan decides to cover a drug that's not on its drug list, or to waive a coverage rule.
A tiering exception is when a drug plan decides to charge a lower amount for a drug that's on its non-preferred drug tier. You or your prescriber must request an exception, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.
Elite Health Plan can make changes to its drug list during the year under guidelines set by Medicare. Elite Health Plan may change its drug list during the year when drug therapies change, new drugs are released, or new medical information becomes available
When can Elite Health Plan change its drug list (formulary) ?
Elite Health Plan does have a coinsurance on certain formulary tiers. Your coinsurance may increase for a particular drug when the manufacturer raises the price. Your copayment or coinsurance may also increase if you continue to take a brand-name drug or original biological product after Elite Health Plan adds a generic or biosimilar form of a drug to the drug list (formulary) and moves the brand-name drug or original biological product to a higher cost-sharing tier.
What are formulary Tiers?
To lower costs, Elite Health Plan places drugs into different “tiers" or levels on our drug lists. Each plan can divide its tiers in different ways. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
Example of a Medicare drug plan's tiers (your plan’s tiers may be different):
Tier 1—Preferred Generics: lowest copayment: most generic prescription drugs
Tier 2—Generics: medium copayment: higher cost or less commonly used generic drugs.
Tier 3—Preferred Brand Drugs: medium copayment: preferred, brand-name prescription drugs
Tier 4—Non-Preferred Drugs: higher copayment: non-preferred, brand-name prescription drugs and some higher cost generic drugs.
Tier 5—Specialty tier—highest copayment: very high-cost prescription drugs
Tier 6—Select Care Drugs - This tier includes select care drugs to Help promote health and adherence.
In some cases, if your drug is in a higher tier and your prescriber thinks you need that drug instead of a similar drug in a lower tier, you or your prescriber can ask your plan for an exception to get a lower coinsurance or copayment for the drug in the higher tier. Plans can change their drug list at any time. Elite Health Plan must notify you of any changes to their drug list that affect drugs you’re taking.
What is the difference between Brand-name drugs and generic drugs?
Both brand-name and generic drugs must be approved by the Food and Drug Administration (FDA) before they can be prescribed to people. Brand-name drugs are marketed under exclusive, trademark-protected names and are protected by patents. When those patents run out, other companies will often produce generic versions that use the same active ingredients.
Is Medicare negotiating prices for certain brand-name drugs?
Medicare is negotiating the price of certain expensive brand-name Medicare Part B and Part D drugs that don’t have competition. More brand-name drugs get added to the negotiations every year.
What drug prices have been, or are being, negotiated?
Prices for the initial 10 drugs that Medicare negotiated with participating drug companies will take effect on January 1, 2026. Contact Elite Health Plan for details on how these negotiated prices will affect you. Every year, Medicare will negotiate the cost of additional drugs.
What are generic drugs?
Generic drugs are copies of brand-name drugs and are the same as those brand-name drugs in:
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Dosage form
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Safety
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Strength
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Route of administration
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Quality
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Performance characteristics
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Intended use
Generic drug makers must prove to the FDA that their product works the same way as the brand-name drug. In some cases, there may not be a generic version of the exact brand-name drug you take, but there may be another generic drug that will work for you. You may save money by using generic drugs instead of brand-name drugs. Talk to your provider to find out if a generic version of a drug would work for you.
What are Biological products and biosimilars?
A biological product is a prescription drug that is made from natural and living sources like animal cells, plant cells, bacteria, or yeast. A biosimilar is a biological product that must be highly similar to and have no clinically meaningful differences from the original biological product in terms of safety and effectiveness. An interchangeable biosimilar may be substituted for the original biological product at the pharmacy without a new prescription, subject to state laws.
Tip: You may save money by using biosimilars instead of original biological products. Talk to your provider to find out if a biosimilar version of a biological product would work for you.
What are the different Medicare drug coverage stages?
Generally, Medicare drug plans and Medicare Advantage Plans with drug coverage have 3 stages:
Deductible stage: If your Medicare plan has a deductible, you pay all out-of-pocket costs until you reach the full deductible. No Medicare drug plan may have a deductible more than $615 in 2026. Some Medicare drug plans like Elite Health Plan don’t have a deductible.
Initial coverage stage: After you reach your full deductible (if your plan has a deductible), you’ll pay 25% of the cost as coinsurance for your generic and brand-name drugs until your out-of-pocket spending on covered Part D drugs reaches $2100 in 2026 (including certain payments made on your behalf, like through the Extra Help program). Then, you’ll automatically get “catastrophic coverage.” Elite Health Plan offers Tiers on the formulary or combination of copays and coinsurance in this stage of the benefit.
Catastrophic coverage stage: You won’t have to pay out-of-pocket for covered Part D drugs for the rest of the calendar year. When you have Medicare drug coverage, you’ll get an Explanation of Benefits (EOB) the month after the pharmacy bills your plan. Your EOB shows the prescriptions you filled, what your plan paid, what you and others have paid, your coverage stage, and what counts toward your out-of-pocket costs and your total drug costs.
What is the coverage for drugs you get in a hospital or Skilled Nursing Facility (SNF)?
Generally, drugs you get in a hospital or SNF are covered by Medicare Part A (Hospital Insurance) as part of your inpatient treatment during a covered stay.
What is the coverage for Drugs you get in a nursing home or other institution?
If you have drug coverage and live in a nursing home or other long-term care facility, you’ll get your covered drugs from a long-term care pharmacy that works with Elite Health Plan. This long-term care pharmacy usually contracts with (or is owned and operated by) your facility. Learn more about care and drugs in a nursing home or other institution.
What about drugs you get in hospital outpatient settings?
In most cases, Medicare Part B (Medical Insurance) doesn’t cover the drugs you get in a hospital outpatient setting (like an emergency department or during observation services). These are sometimes called "self-administered drugs" that you would normally take on your own. Your Medicare drug coverage may cover drugs you get in a hospital outpatient setting under certain circumstances.
What about End-Stage Renal Disease (ESRD) drugs?
If you have End-Stage Renal Disease (ESRD), Medicare Part B (Medical Insurance) will pay for some of the drugs you need, like injectable drugs and their oral forms, and biologicals including erythropoiesis stimulating agents used for dialysis.
Your Medicare drug coverage will cover most ESRD-related drugs that are available only in oral form. Get more information about ESRD coverage.
What about Vaccine coverage?
Medicare Part B (Medical Insurance) covers certain vaccines (like COVID-19, flu, hepatitis B and pneumococcal vaccines).
Medicare drug coverage must cover all commercially available vaccines (like shingles, RSV, tetanus, diphtheria, and pertussis) when medically necessary to prevent illness. You pay nothing out of pocket for Part D adult vaccines recommended by the Advisory Committee on Immunization Practices.
Using your drug coverage
You can use your Elite Health Plan Medicare prescription drug coverage at your local retail pharmacy.
What do I bring to the pharmacy?
To fill your prescription, bring: Your Elite Health Plan Medicare Prescription Drug Identification card
Filling a prescription without your new plan card
If you need a prescription filled at your pharmacy before you get your new drug plan card, you can prove you have coverage by showing:
The acknowledgement, confirmation, or welcome letter you got from Elite Health Plan.
An enrollment confirmation number you got from the plan, and the plan name and phone number.
A copy of your official Medicare card that you can print by logging in (or creating) your secure Medicare account.
If you don't have any of these items, your pharmacist may still be able to get your drug plan information. You'll need to give them your Medicare Number or the last 4 digits of your Social Security Number.
If your pharmacist can't get your drug plan information, your doctor may be able to give you a sample of your prescription drug to help you get by until your coverage is confirmed, or you may have to pay an out-of-pocket cost for your drugs. If you do pay out-of-pocket for your drugs, save your receipts, and contact Elite Health Plan.
What is a Formulary?
A formulary is a list of covered drugs selected by Elite Health Plan, 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. Elite Health Plan will generally cover the drugs listed in our formulary for as long as the drug is medically necessary, the prescription is filled at an Elite Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
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 that 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-share 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, add prior authorization criteria, 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.
What about Generic Drugs?
Elite Health Plan 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.
What if my drug isn't on the formulary?
If your drug is not included on this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that Elite Health Plan does not cover your drug, you have two options:
You can ask Member Services for a list of similar drugs that are covered by Elite Health Plan. When you receive the list, share the list with your doctor and ask him or her to prescribe a similar drug that is covered by Elite Health Plan.
You can ask Elite Health Plan to make an exception and cover your drug.
What is Part D and what does a Part D prescription drug plan cover?
Most Medicare Advantage Plans include Part D coverage. Part D is the part of Medicare that provides coverage for your needed drugs and medications. If you do not have Medicare Part D coverage, you do not have coverage for prescription drugs. Refer to your plan materials for more information about your Part D benefit.
Where can I find my drug list?
Your drug list, also called a formulary, is a list of prescription drugs that may be covered in your health plan. The drug list shows the most comprehensive drugs on your plan and is regularly updated. You can find your drug list in your secure member portal or on your health plan website. www.elitehealthplan.com/formulary
What if my drug is not on the list?
If you currently take a drug that is not on your drug list, please check your plan's formulary for details on which alternative drugs are covered, Talk to your doctor to see if any alternative drugs will work for you. www.elitehealthplan.com/formulary
How much will I pay for my prescription drugs?
Your out-of-pocket prescription costs will not exceed $2,100 during the plan year.
Medicare places drugs into different cost levels called “tiers.” Plan types may vary in the number of tiers offered.On most of our plans, you will pay $0 for Tier 1 and Tier 6 medications. We offer a wide variety of generic drugs on these tiers, and also cover the generic erectile dysfunction drug – sildenafil on Tier 2 at a quantity limit.
Other tiers may have a coinsurance where you pay a percentage of the total drug cost. Your costs can vary depending on the drug and pharmacy that you use.
Does my plan cover shots and vaccines?
Yes, all adult, ACIP-recommended Part D vaccines, such as RSV and Shingles, are available at no cost to you.
Does my plan include insulin?
Yes, you can get a 30-day supply of all covered insulins for the lesser of 25% of the cost of the medication or $35.
Why should I use an in-network pharmacy?
You can save on out-of-pocket drug costs by using an in-network pharmacy.
We have over 60,000 pharmacies in our network with both local and retail pharmacies for you to choose from. Our partnerships with CVS and Walgreens and most grocers ensure that you can find an in-network pharmacy that is close to you.
Use the Find a Pharmacy Tool to find a preferred pharmacy near you.
Can I have my prescriptions mailed to my home?
You can save time and trips to the pharmacy through Mail Order Pharmacy. Get up to a 90-day supply of your prescription drugs sent to your home with BirdiRx Pharmacy. Standard shipping is free! Mail Order is only available for medications on Tiers 1, 2, 3, and 6.
Your prescriptions are delivered to your door in discreet packaging. You can track your medication delivery and get updates by email, phone, or text to make sure you have your medications when you need them.
What if my medications need prior authorization or approval?
Some medications need prior authorization, or pre-approval, and are noted with a “PA” in your drug list.
If you are prescribed a medication that requires pre-approval, your doctor will need to submit a prior authorization form requesting the drug for you.
What if I can not afford my medications?
If you're having a hard time paying for the prescription drugs you need, don’t stop taking your medicine or reducing the amount you take. Taking your medication as prescribed by your doctor helps keep you healthy. Talk to your doctor about your medication options. Your doctor can recommend drugs that may cost less and may work better for you.
The Medicare Prescription Payment Plan is a new payment option that works with your current drug coverage and can help you manage your drug costs by spreading them across monthly payments that vary throughout the year from January to December.
To learn more, visit www.elitehealthplan.com/MPPP.
What about Compounded drugs and their coverage?
Compounded drugs are produced by mixing or altering the existing prescription medications for a variety of reasons. Sometimes, an individual cannot use the standard version of the product because of an allergy to one of its ingredients. In other cases, the right dosage form is not readily available, so the commercially offered drug products need to be transformed into a different form. For people who can’t swallow tablets or capsules, compounding procedures can customize a drug into a powder, liquid, lozenge, suppository, or another form.
Compounded medications are not approved by the Food and Drug Administration (FDA), unlike drugs listed in our formulary. Without the FDA oversight, there is an extra risk factor involved when a compounded product is prepared because it is not tested for purity, stability, safety, effectiveness, or dosage. Since the quality of compounded products may be compromised, the FDA recommends using an approved product that has undergone rigorous testing instead of a compounded medication when possible.
Our plan does not cover all compounded medications. In some cases, certain compounded
products are “excluded” from coverage by Medicare. In other cases, we have decided not to
cover a particular compounded product. To ensure the appropriate utilization of compounded medications, certain rules and restrictions may apply e.g., Prior Authorization and Quantity Limit requirements, etc.
Our members are advised to use compounded medication only when it is medically necessary. If you have questions about compounded medications and their coverage, please call Member Services.
Additional questions?
If you have questions about your pharmacy benefits or coverage, please call the Member Services number on the back of your Member ID card.
From April 1 to September 30, you can call between 8 am and 8 pm Monday thru Friday.
From October 1 to March 31, you can call between 8 am and 8 pm every day.