ANSWERS COMMON QUESTIONS
Frequently Asked Questions
Below are answers to frequently asked questions. This information can help you find answers to help you understand your plan. However, if you don’t find what you’re looking for please call Member Services at 866-250-2005 24 hours a day, 7 days a week (TTY, call 711). You may also submit a question through our web form.
Note: If you are a member of a group retiree plan, please sign in to your plan information, or contact your human resources department.
What plans are offered by Elixir Insurance?
Elixir Insurance, a Medicare-approved Prescription Drug Plan (PDP) offers the Elixir RxPlus and Elixir RxSecure Medicare Part D plans. Plan type availability is dependent on zip code. Elixir Insurance is available in all 50 states, Puerto Rico, Guam and the District of Columbia; however, benefits vary by state. You can find information about the coverage available in your area by using our Find a Plan resource. If you are a retiree interested in benefits through your employer retiree plan, contact your human resources department.
How do I enroll?
You may enroll on this website or call Member Services to enroll or request an information packet. Call 24 hours a day, 7 days a week: 1-888-377-1439 (TTY: 711). If you are a retiree interested in benefits through your employer retiree plan, contact your human resources department.
You may also download an application for the Elixir RxPlus or Elixir RxSecure plan, print, complete and mail to: Elixir Insurance, 7835 Freedom Avenue NW, North Canton, OH 44720. You will be notified by mail when your enrollment has been accepted.
You may also enroll in Elixir Insurance through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Please note that by clicking on this link you will be leaving the Elixir Insurance website. You may also call 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048), 24 hours a day, 7 days a week.
Where can I find my Member ID Card?
We mail Member ID cards to members within ten days of enrollment. If you lost your ID card you can download and print through the Member Portal. You can also call Member Services to order a new ID card.
What is a Power of Attorney?
A power of attorney (POA) or letter of attorney is a written authorization to represent or act on another's behalf.
How do I appoint a Power of Attorney or Authorized Representative to Act on My Behalf?
You may give another person, known as your agent or attorney-in-fact, power of attorney as long as you're mentally competent. You must draft a power of attorney document that meets the legal requirements in your state in order to give your agent authority. Once you've chosen an agent, you need to decide what type of powers you want to give them and when.
You can allow someone to be your Authorized Representative to act on your behalf by submitting the Appointment of Representative form to Elixir Insurance. You can also use a form directly from Medicare to assign this. That document can be found here: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207.html. Please note: by clicking this link you will be leaving the Elixir Insurance website.
What should I do if I have other or secondary prescription drug coverage?
Please call our helpdesk at 1-866-250-2005. They will provide information on the steps that need to be taken.
How Can I Request Information Related to Grievances, Appeals and Exceptions?
You may request aggregate numbers of grievances, appeals, and exceptions filed with Elixir Insurance, or specific information regarding the status of grievances or appeals you have filed, by calling Member Services at 1-866-250-2005 (TTY/TDD users may call 711). Member Services is open 24 hours a day, 7 days a week.
Or visit the CMS Medicare website at www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp. Please note by clicking on this link, you will be leaving the Elixir Insurance website.
For more information regarding grievances, coverage determination requests, or appeals, refer to Chapter 7 of your Evidence of Coverage.
How do I submit a grievance?
How do I disenroll?
In order to disenroll from Elixir Insurance, the plan must receive a written request to disenroll from you, within a valid election period. Generally, you may only enroll or disenroll in a Medicare Part D plan once a year during the Annual Election Period (AEP) which is from October 15th through December 7th each year unless you qualify for a Special Election Period (SEP). If you believe that you qualify for an SEP reason, you can submit a written disenrollment form to the plan via USPS at 7835 Freedom Avenue NW, North Canton, OH 44720 or you may fax the request to 1-866-250-5178. You can also submit a disenrollment request electronically on our website at www.elixirinsurance.com. Please click here for more information about disenrolling. After we receive your disenrollment form, Elixir Insurance will validate the SEP reason and submit the request to Medicare for approval. The plan will mail a termination letter with a disenrollment effective date upon submission of the disenrollment. Please note: if you enroll in another Medicare Part D plan you will automatically be disenrolled from Elixir Insurance because you can only have one Medicare Part D plan at a time.
If you are a group retiree member, please visit the Member Portal to see your Evidence of Coverage.
What is your Best Available Evidence Policy?
CMS created the “best available evidence” policy in 2006 requiring plans to establish appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information was not accurate. CMS continues to require Part D plans to rely on best available evidence and considers it best practice for the Part D plans to work with pharmacies to resolve these issues at point-of-sale when beneficiaries provide appropriate evidence of correct low-income status.
More information can be found on the Medicare website. Please note: by clicking on this link you will be leaving the Elixir Insurance website.
How do I report Fraud, Waste & Abuse?
We are committed to following all applicable laws and regulations to ensure compliance with federal healthcare program requirements. As part of our compliance program efforts, Elixir Insurance is committed to detecting, correcting and preventing Fraud, Waste and Abuse (FWA).
- Fraud is knowingly and willfully executing, or attempting to execute, a scheme to defraud any health care benefit program, or to falsely obtain any of the money or property that belongs to any health care benefit program.
- Waste includes overusing services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
- Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. It involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
If you identify potential Fraud, Waste or Abuse (FWA) activities involving Elixir Insurance members, pharmacies or prescribers you may anonymously report the suspicions online, call member services at 1-866-250-2005 (24 hours a day, 7 days a week. TTY, call 711.) or call the Compliance and Ethics Hotline at 1-866-417-3069.
Does my plan have a deductible?
Yes, there is a deductible and it varies by state and your plan selection. The deductible may apply to all your covered drugs or, for some states, the deductible only applies to tier 3, 4 and 5 drugs listed on the formulary. Click on FIND A PLAN in your menu bar, enter your zip code and click on GET STARTED to see deductible options.
When can I refill my prescriptions?
Elixir Insurance has a 75% refill tolerance which means the plan will cover a refill of your covered medications once 75% of the medication should have been used. For example, 75% of a 30 day supply is roughly 23 days which means the next claim will process on 23 days after the original prescription. Another example, 75% of a 90 day supply is roughly 68 days which means the next claim will process on 68 days after the original prescription. However, please be advised that many pharmacies have their own policies with regard to medication refills. Pharmacies may not refill certain medications until all of the medication has been used. We suggest that you talk to your pharmacy about their refill policy to avoid any further issues.
Is it necessary to have prescription coverage?
Once you qualify for Medicare, you should have prescription coverage or you risk a Late Enrollment Penalty (LEP) from the Centers for Medicare & Medicaid Services. Besides the LEP, the cost for prescription medications continues to grow each year. Enrolling in a Medicare approved prescription drug plan helps you to reduce your out-of-pocket costs for prescription drugs. Elixir Insurance uses a prescription drug formulary to lower your costs and ensure access to quality, safe, and cost effective medications.
What if a medication I’m already taking is not included on the Plan Formulary or Drug List?
To ease your transition into the Elixir Insurance plan, allowances will be made during the first 90 days of coverage to allow time for you to continue on your current medication, while you and your physician discuss your alternative medication treatment options. View drugs listed in our formulary. If you are a group retiree member, to see your formulary you must sign in.
How much are my drugs?
Use our drug pricing tool to get information on your prescription drug medications and their pricing. If you are a group retiree member, you must sign in to see accurate drug pricing.
What drugs require Step Therapy, have Quantity Limits or require Prior Authorization?
If you are a group retiree member, you must sign in to find this information. The lists below are applicable for individual PDP members.
How do I submit an appeal?
You can request an appeal when you want us to reconsider at adverse coverage determination made regarding what prescription drugs are covered or what we will pay. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage. Submit an appeal through one of the options below. Learn more about filing appeals here.
- Online – click on one of the links below Standard Appeal (Elixir Insurance has seven calendar days to respond) Fast Appeal (Elixir Insurance has 72 hours to respond. Only use if waiting for a standard appeal could seriously harm your health).
- Download Request for Redetermination form, print, complete and mail or fax your appeal.
- Fax: 1-877-503-7231
- Mail to: Elixir Insurance, Attn: Appeals/Coverage Determinations (Clinical Services), 7835 Freedom Avenue NW, North Canton, OH 44720
- Call: 1-866-250-2005 (TTY/TDD users should call 711)
What is the transition policy for formulary changes or new members (also called the Plan Transition Process)?
We have a transition process in place to help new members when a drug they are taking is not covered by the plan, or when existing members are impacted by a formulary change. More about our plan transition process is available on this site, or review your Evidence of Coverage for more information.
What is a formulary?
A formulary is a list of covered drugs selected by Elixir Insurance in consultation with a team of health care providers, which represents both brand and generic drugs in Medicare Part D Eligible Therapy Drug Classes. Elixir Insurance will cover the drugs listed in our formulary as long as the drug is being used for a medically accepted diagnosis and you meet the Medicare approved criteria if required. Please note that you should fill your prescription(s) at an Elixir Insurance preferred network pharmacy for best pricing. For more information on how to fill your prescriptions, please review your Evidence of Coverage or contact our Member Services Help Desk at 1-866-250-2005. The formulary may change at any time. You will receive notice when necessary. If you are a group retiree member, to see your formulary you must sign in.
Why am I receiving calls asking to review my medications over the phone?
You may receive a call about your medication if you qualify to receive a comprehensive medication review and/or a medication adherence assessment from our Medication Therapy Management (MTM) department or one of our partners. Both of these services are offered at no cost to qualifying members of our plan and we encourage you to take advantage of this valuable opportunity.
To protect your privacy, MTM representatives will always verify your identity before discussing your medications. They may ask you to verify your name, date of birth, zip code, or other contact information but will never ask you for sensitive information such as your social security number or your bank account number.
For more details about our MTM program, please visit the "MTM Program" section of our website.
Which pharmacies can I use to get covered prescriptions filled?
There are thousands of pharmacies nationwide that participate in the Elixir Insurance national network, including Rite Aid. Find other pharmacies using our pharmacy look up tool. We also offer home delivery through Elixir Pharmacy for maintenance and specialty drugs. The pharmacy network may change at any time. You will receive notice when necessary. If you are a group retiree member, you must sign in to find pharmacies in your plan’s network.
Does your plan have Preferred Pharmacies with reduced copays or co-insurance?
Elixir Insurance has a Preferred Pharmacy Network, which offers a lower cost-sharing for our members. Contact a Member Services Representative or to Find a Pharmacy and search for pharmacies in your area. If you are a group retiree member, you must sign in to find pharmacies in your plan’s network.
Can I get my prescriptions through mail order?
Yes. Elixir Insurance offers mail order prescriptions through Elixir Pharmacy is—a preferred pharmacy in our network. You can get maintenance and specialty drugs delivered to your home. For details about delivery timelines and contact details, please visit their website at Elixir Pharmacy. If you are a member of a group retiree plan, you should verify that Elixir Pharmacy is in your network. Please review your Pharmacy Directory or contact the plan to be sure.
Can I fill prescriptions outside of the network?
We may cover drugs filled at an out-of-network pharmacy only if there are no participating pharmacies near you and in an event of an emergency as defined by the plan. (Up to a 30-day supply only). Call Member Services to see if there is a network pharmacy in your area, and if not, verify that Elixir Insurance will allow an out of network pharmacy before you fill your prescription.
If you do go to an out-of-network pharmacy due to a health emergency, you may have to pay the full cost (rather than paying just your copayment), when you fill your prescription. You can submit a claim form for reimbursement by downloading and submitting a reimbursement form. This form must be completed and returned along with your original paper receipt from the pharmacy within 90 days of receiving your prescription. Reimbursement will be the amount that we would have paid if you had the prescription filled at a network pharmacy. The amount that you paid may still be counted towards your required out-of-pocket costs. Please mail the form and receipts to Elixir Insurance – 7835 Freedom Avenue NW, North Canton, OH 44720. For more information about outside network pharmacies, please reference your Evidence of Coverage or search our pharmacy network online this site.
When will my automatic payment get deducted from my account?
Automatic payments get processed on the third business day of every month.
When will my automatic payment get posted to my account?
Please allow 24-48 hours for your automatic payment to be applied to your account.
I signed up for automatic checking account deduction. Is there a delay in the processing time?
Yes, please allow two additional business days for the deduction to appear on your account.
Will I receive an invoice if I am getting automatic payments withdrawn from my account?
No, you will not receive an invoice if you have automatic payments withdrawn.
I signed up for Social Security Administration deductions, but I still received a bill. Why am I getting a bill?
Please contact Social Security to verify when your premiums started to be deducted from your Social Security check. Any premiums for the months billed prior to the effective date of the Social Security deductions will still be your responsibility to pay.
If I am set up with the Social Security Administration deductions, will I get an invoice?
No, you will not receive an invoice from us unless there is a premium that was due prior to the effective date of the Social Security deduction.
Can I pay ahead for the full year? Can I pay quarterly?
Yes, you can pay ahead of time for as many months as you would like.
Will I get a bill or invoice if I pay ahead of time?
No, if you have a credit balance (prepaid) on your account, you will not receive an invoice.
How do I update my account information for automatic payments?
You can update your account on the website under Setup Automatic Payments or you can contact our helpdesk at 1-866-250-2005 for assistance.