Welcome to Elixir RxPlus

IMPORTANT NOTICE: Elixir Insurance will no longer offer any individual Medicare prescription drug plan as of January 1, 2024. Your prescription drug coverage through Elixir Insurance will end on January 1, 2024. You will need to join another Medicare prescription drug plan to continue to receive prescription drug coverage in 2024. Click here* to view a list of alternate plans for your consideration. You may also search for other plans to meet your needs. For former EI members, please refer to the documentation that was mailed to you on 10/04/2023 for your options. Please be sure to change your plan and call us at 855-438-3173 , TTY 711, to avoid any disruptions in your mail order or specialty pharmacy prescriptions.

Members of an Employer Group are excluded.

STANDARD APPEAL

Prefix *

First Name *

Last Name *

Member ID *

Phone Number *

Physician First Name *

Physician Last Name *

Physician Phone Number *

Physician Fax Number

Drug Name *

Drug Strength *

Exception Request Type *

Person Submitting Request *

Requester First Name *

Requester Last Name *

Requester Phone *

Please provide your rationale for disagreeing with our initial decision as well as any additional medical information that we should consider when processing your appeal *

Our plans are provided by Elixir Insurance Company. Elixir Insurance is a Prescription Drug Plan with a Medicare contract. Enrollment in Elixir Insurance depends on contract renewal. The pharmacy network may change at any time. You will receive notice when necessary.

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Information Required

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