Other Information

Utilization Management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our participants 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 participants:

Quantity Limit Approval List

For certain drugs, Elderplan FIDA Total Care (Medicare-Medicaid Plan) limits the amount of a drug you can get. For example, Elderplan provides 30 tablets for 30 days for pioglitazone tablets. 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 (PBM) at CVS/caremark at 1-866-443-0935 or Participant Services at 1-855-462-3167. The TTY number for the hearing impaired is 7-1-1. Participant Services is available seven days a week between the hours of 8:00 a.m. and 8:00 p.m.

2017 Quantity Limit Approval List English | Spanish

Prior Approval Criteria List

Certain drugs need authorization from Elderplan FIDA Total Care before you fill your prescription. Please click on the Prior 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 (PBM) (PBM) at CVS/caremark at 1-866-443-0935 or Participant Services at 1-855-462-3167, or the TTY number for the hearing impaired, 7-1-1, seven days a week between the hours of 8:00 a.m. and 8:00 p.m.

2017 Prior Authorization Approval List English| Spanish

Prior Authorization Request Form

Step Therapy List

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. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second. 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 (PBM) at CVS/caremark at 1-866-443-0935 or Participant Services at 1-855-462-3167. The TTY number for the hearing impaired is 7-1-1. Participant Services is available seven days a week between the hours of 8:00 a.m. and 8:00 p.m.

2017 Step Therapy List English | Spanish

Drug Utilization Review

We conduct drug utilization reviews for all of our participants to make sure that they are receiving safe and appropriate care. These reviews are especially important for participants 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

Additional Documents

Participant Reimbursement Form
Model Coverage Determination Request (English)or visit www.cms.gov
Model Coverage Determination Request (Spanish)