Plan information is available for free in other languages. Please call our member service number at 1-866-250-2005 (TTY: 711) 24 hours a day, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro Cuidado al Cliente, al 1-866-250-2005 (teléfono de texto (TTY): 711), las 24 horas del día, los 7 días de la semana.

• Other Pharmacies are available in our network.
• The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
• This is not a complete list of drugs covered by our plan. For a complete listing, please call Member Service Phone and TTY Numbers or visit Elixirinsurance.com.
  • This directory is for a geographic area.
  • We also list pharmacies that are in our network but are outside a geographic area.
• The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, please call 1-866-250-2005 (TTY: 711) 24 hours a day, 7 days a week or consult the online pharmacy directory at Elixirinsurance.com.

Please Read this Important Information. If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have prescription drug coverage from your Medicare Advantage Plan that will meet your needs. By joining Elixir Insurance, your membership in your Medicare Advantage Plan may end. This will affect both your doctor and hospital coverage as well as your prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if you have questions, contact your Medicare Advantage Plan. If you currently have health coverage from an employer or union, joining Elixir Insurance could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Elixir Insurance. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

By completing an enrollment application, you agree to the following: Elixir Insurance is a Medicare drug plan and has a contract with the Federal government. I understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare Part A or Part B coverage. It is my responsibility to inform Elixir Insurance of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare prescription drug plan at a time – if I am currently in a Medicare Prescription Drug Plan, my enrollment in Elixir Insurance will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period (October 15 – December 7), unless I qualify for certain special circumstances.

Elixir Insurance serves a specific service area. If I move out of the area that Elixir Insurance serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies except in an emergency when I cannot reasonably use Elixir Insurance network pharmacies. Once I am a member of Elixir Insurance, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Elixir Insurance when I get it to know which rules I must follow to get coverage.

I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the future.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Elixir Insurance, he/she may be paid based on my enrollment in Elixir Insurance.

Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid program, and the Medicare Savings Program.

By joining this Medicare prescription drug plan, I acknowledge that Elixir Insurance will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Elixir Insurance will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes, which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under State law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by Medicare.

Elixir Insurance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Elixir Insurance does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Elixir Insurance:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Written information in other formats (large print and accessible electronic formats)
• Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages

If you need these services, contact Member Services.If you believe that Elixir Insurance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Elixir Insurance: mailing address: 7835 Freedom Avenue NW, North Canton, OH 44720, Member Services: 1-866-250-2005, TTY: 711, fax: 1-877-503-7231. If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Please note: By clicking on any of these links, you will be leaving the Elixir Insurance website.