Pharmacy Information &

Prescription Drug Coverage

For Drug coverage, what’s the difference between Medicare Part B and Part D?

Coverage Determination Request Form Part B versus D Coverage (PDF): English | Español

Medicare Part
Drug Coverage

Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions.

Usually, Part B covers drugs you wouldn’t typically give to yourself, like those you get at a doctor’s office or in a hospital outpatient setting.

Medicare Part
Drug Coverage

Medicare drug coverage (Part D) covers a wide range of prescription drugs that people with Medicare take. A list of covered drugs is called a “formulary,” and each plan has its own formulary. Medicare drug coverage typically places drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost.

View Part Drug Coverage View Part Drug Coverage

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2025 Part B Drug Coverage

Part B Drug Prior Authorization Requirements
For certain Part B drugs, prior approval or prior authorization from the plan may be required before the drug is covered. To learn more about the Part B drugs that require prior authorization, view the document below.

2025 Part B Prior Authorization Drug List (PDF): English | Español
Part B Drug Step Therapy Criteria
In some cases for Part B Drugs, Aspire Health Plan may require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called Step Therapy. For more details on Step Therapy, view the document below.

2025 Part B Step Therapy Updates (PDF): English | Español

Part B Drug Prior Authorization Request
For drugs with prior authorization or step therapy requirements, your doctor will need to submit a Part B Prior Authorization Request Form. You may view this document below

2025 Part B Prior Authorization Request Form (PDF):
(Last Revised 4/2024) English | Español

Part B Drug Clinical Policies

Aduhelm (aducanumab) Clinical Policy

Beovu (brolucizumab) Clinical Policy

Botulinum Toxin Policy

Evenity (romosozumab-aqqg) Clinical Policy

Eylea (aflibercept) Clinical Policy

Hyaluronic Acid Derivatives Clinical Policy

Infliximab Products Clinical Policy

Kisunla (donanemab-azbt) Clinical Policy

Lemtrada (alemtuzumab) Clinical Policy

Leqembi (lecanemab-irmb) Clinical Policy

Leuprolide Long-Acting (Lupron Depot, Eligard, Fensolvi, Camcevi, Lutrate Depot)

Ocrevus (ocrelizumab) Clinical Policy

Off-Label Use of Drugs and Biologic Agents

Oncology Drugs and Biosimilars Policy

Part B Medical Necessity Policy

Prolia (denosumab) Clinical Policy

Ranibizumab Products Clinical Policy

Reblozyl (luspatercept-aamt) Clinical Policy

Rituximab Products Clinical Policy

Tepezza (teprotumumab-trbw) Policy

Tysabri (natalizumab) Clinical Policy

Vabysmo (faricimab-svoa) Clinical Policy

Xgeva Products(denosumab) Policy

Zilretta (triamcinolone acetonide ER injection) Clinical Policy

2025 Part D Pharmacy Drug Coverage

Prescription Drug Formulary
Aspire Health Plan’s prescription drug formulary or “Drug list” is a list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.

To search for a specific prescription drug, view our 2025 Online Drug Formulary

2025 Formulary (PDF):
(Last Revised 4/2025) English | Español
Pharmacy Directory
To search for a specific pharmacy, view our Interactive Online Pharmacy Directory.

2025 Pharmacy and Provider Guide (PDF):
(Last Revised 4/2025) English | Español
Step Therapy
In some cases, Aspire Health Plan may require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called Step Therapy. For more details on Step Therapy, view the document below.

2025 Step Therapy Updates (PDF): English
Prior Authorization
You have the right to request an exception to the Aspire Health Plan Drug Formulary. To learn more on the types of exceptions, view the document below.

2025 Prior Authorization Updates (PDF): English

Coverage Determination Request
Request for Medicare Prescription Drug Coverage Determination (PDF):
(Last Revised 9/2019) English | Español
Mail-Order Prescriptions
If you rely on regular or long-term medications, there may be a better way to get your prescriptions filled. Birdi Rx is home delivery and a smart, simple way for you to get prescriptions delivered to your door.

2025 Home Delivery Registration Form (PDF): English | Español
100-Day Medication Supplies
You can receive 100-day supplies of your Medicare Part D medications at a discounted cost of only two co-pays. If your prescription is not initially written for a 100-day supply, please consult with your pharmacist or prescriber to explore options for obtaining a new prescription tailored for a 100-day supply.

Pick up a 100-day supply of your maintenance medications at participating pharmacies or by mail order. This program offers both convenience and cost savings. Sign up for Mail-Order Home Delivery with the forms above, or call 888-495-3160.
Out-of-Network Pharmacy Coverage
For a detailed description of our out-of-network pharmacy rules, check out our Evidence of Coverage documents located on our 2025 Plan Documents page.

Medicare Prescription Payment Plan

Medication Prescription Payment Plan

The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your out- of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary.

To learn more visit the Medication Prescription Payment Plan webpage.

Extra Help for Part D Drugs

Are you an Aspire Health Protect (HMO), Aspire Health Value (HMO), Aspire Health Advantage (HMO), Aspire Health Plus (HMO-POS) or Aspire Health Group Plus (HMO-POS) member or potential member with limited income and resources?

People with limited incomes may qualify for extra help to pay for their prescription drug costs: the Low Income Subsidy (LIS).

Additionally, those who qualify will not be subject to the deductible stage (if applicable), coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it.

We can help you find out if you are eligible. If you qualify, you may have lower monthly premiums for the prescription drug coverage under your Aspire Health Plan. You also may have lower cost sharing for your prescriptions.

For general information about Extra Help, please call toll-free 1-800-MEDICARE (1-800-633-4227), or toll-free 1-877-486-2048 (TTY for the hearing/speech impaired), 24 hours a day, seven days a week. Or visit medicare.gov.

You also may call:

Our Member Services department locally at (831) 574-4938 (TTY 711), or toll-free at (855) 570-1600 (TTY 711), seven days a week, 8 a.m. to 8 p.m
Social Security toll-free at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday, or toll-free at 1-800-325-0778 (TTY for the hearing/speech impaired). Or visit the Social Security website at ssa.gov
Your state Medi-Cal office

Apply for extra help online at ssa.gov

2025 Low Income Subsidy Summary (PDF): English | Español

Best available evidence (BAE)

If you think you are eligible for Medicare’s extra help and that you are not paying the correct monthly premium or costs for your drugs, you or your appointed representative may be able to correct your Medicare records by providing us with information, known as Best Available Evidence (BAE), about your eligibility for extra help.

When we receive and verify your BAE, we will share it with Medicare and also update our records within 3 business days. You also will need to provide the information to a network pharmacy when you obtain prescriptions so that we can charge you the appropriate cost-sharing amount until Medicare updates its records to reflect your current status.

Acceptable examples of BAE documents include copies of the following.

your state Medicaid card
your extra help Social Security award letter
Supplemental Security Income (SSI) Notice of Award with an effective date
a state document that confirms your active Medicaid status
other official state documentation showing your Medicaid status
a Home and Community-Based Services (HCBS) Notice that includes your name and HCBS eligibility date

For members who are institutionalized or in a long-term care facility, an appointed representative can provide a copy of the following BAE examples:

a remittance from the facility showing Medicaid payment for a full calendar month with that individual’s name on the statement
a copy of a state document that confirms Medicaid payment to the facility for a full calendar month on behalf of the individual
a screen printout from the state’s Medicaid information system showing that individual’s institutional status based on at least a full calendar month stay for Medicaid payment purposes

You or your appointed representative can mail a copy of your BAE document with your medical or health record number to:

Aspire Health Plan
Attn: Best Available Evidence
PO Box 5490
Salem, OR 97304

Or you may fax it locally to (831) 574-4939, toll-free at (855) 519-5769.

For more information on Low Income Subsidy and Best Available Evidence (BAE) policy, visit cms.gov.

NOTE: You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, co-payments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

Medication Therapy Management

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program. MTM is a service offered by Aspire Health Plan at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit. This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.

To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program. Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.

To qualify for Aspire Health Plan’s MTM program, you must meet one of the following criteria:

Be an At-Risk Beneficiary or
Meet All of the following criteria
1. Have at least three (3) of the following conditions or diseases:
  Alzheimer’s
  Bone disease arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
  Chronic heart failure
  Diabetes
  Dyslipidemia
  End-stage renal disease (ESRD)
  HIV/AIDs
  Hypertension
  Mental Health (including depression, schizophrenia, and bipolar)
  Respiratory disease (including asthma, chronic obstructive pulmonary disease (COPD))
  AND
2. Take at least 8 covered Part D medications, AND
3. Are likely to have medication costs of covered Part D medications greater than $1,623 per year.

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:

Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, your caregiver, your pharmacist, and/or your doctor if we detect a potential problem.
Comprehensive medication review: at least once per year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This review, or CMR, is provided to you confidentially via telephone. The CMR may also be provided in person or via telehealth at your provider’s office, pharmacy, or long-term care facility. If you or your caregiver are not able to participate in the CMR, this review may be completed directly with your provider. These services are provided on behalf of Aspire Health Plan. This review requires about 30 minutes of your time. Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors. This summary includes:
- Recommended To-Do List (TDL): The list has steps you should take to help you get the best results from your medications.
- Personal Medication List (PML): The medication list will help you keep track of your medications and how to use them the right way.

Use these Personal Medication List (PML) that can help you and your healthcare providers keep track of the medications you are taking.

2025 Medication List (PDF): English | Español

If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please contact customer service at (831) 708-6388 .

2025 Medication Therapy Management (MTM) program (PDF): English | Español

Prescription Drug Transition Policy

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

The change to your drug coverage must be one of the following types of changes: The drug you have been taking is no longer on the plan’s Drug List – or – the drug you have been taking is now restricted in some way.
You must be in one of the situations described below:
- For those members who are new or who were in the plan last year:
  We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of 30 day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30 day supply of medication. The prescription must be filled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
- For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
  We will cover one 31 day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.
- Exceptions are available for members who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Members being admitted to or discharged from a LTC facility will be able to access a refill upon admission or discharge. Examples of situations in which members would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the plan are as follows:
  - If you enter or leave a long-term care facility
  - If you are discharged from a hospital
  - If you leave a skilled nursing facility
  - If you cancel hospice
  - If you are discharged from a psychiatric hospital on a specialized medication

To ask for a temporary supply, call Member Services at (855) 570-1600 (TTY 711). During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out.

Quality Assurance

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes 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:

Possible medication errors
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 allergies
Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Safe Disposal of Prescription Medication

Of the 4 billion prescriptions filled in the United States every year, one-third of them go unused. That’s 200 million pounds of unused medications.1 Unused medications should be disposed of as soon as possible to limit the possibility of illegal use.

Flushing or dumping down a drain is not the best way to dispose of medication. Sewage treatment systems can’t remove all the medications from the water released into lakes, rivers, or oceans in your area.2

So what are the other options?

Medication “Take-Back” Programs – “Take-back” programs allow the public to bring unused drugs to a central location for proper disposal. Call your local government’s trash and recycling service to see if a program is available. In addition:

The DEA allows you to mail back unused prescription medications to pharmacies and other authorized sites using packages made available at pharmacies and other locations.
Most states have agency collection boxes overseen by law enforcement or pharmacies. Call the DEA’s Registration Call Center to find box locations or other disposal sites at 1–800–882–9539, or visit https://safe.pharmacy/drug-disposal or www.dea.gov/takebackday
Community coalitions and law enforcement in your area may sponsor “medication take-back events” periodically.

Disposal in Household Trash

If these programs are not available in your area, place the drugs in the trash by following these steps:

Remove them from their original containers and conceal or remove any personal information, including the Rx number, from the container.
Mix the medications with something inedible, such as coffee grounds or kitty litter.
Place the empty container and the mixture in a sealed bag or empty can.

For additional information, visit:

1 Dispose My Meds. (n.d.). You and the environment. Retrieved from http://disposemymeds.org/environmental-impact/

2 United States Geological Survey. (2014). Pharmaceuticals, hormones, and other organic wastewater contaminants in U.S. s streams. Retrieved from https://www.usgs.gov/programs/environmental-health-program/science/national-reconnaissance-pharmaceuticals-hormones-and

Safe Disposal of Prescription Medication (PDF): English | Español

Give Us a Call

Prospective Members
Toll-free: (866) 798-1530 (TTY 711)

Current Members
Toll-free: (855) 570-1600 (TTY 711)
Local: (831) 574-4938 (TTY 711)

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Aspire Health is a Medicare Advantage HMO plan sponsor with a Medicare contract. Enrollment in Aspire Health depends on contract renewal.

Medicare beneficiaries may also enroll in Aspire Health through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Every year, Medicare evaluates plans based on a 5-star rating system. For accommodation of persons with special needs at meetings call 1-855-570-1600 (TTY: 711) Other Providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Aspire Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1- 877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

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Pharmacy Information &

Prescription Drug Coverage

For Drug coverage, what’s the difference between Medicare Part B and Part D?

Medicare Part Drug Coverage

Medicare Part Drug Coverage

2025 Part B Drug Coverage

2025 Part D Pharmacy Drug Coverage

Medication Prescription Payment Plan

Give Us a Call

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Medicare Part
Drug Coverage

Medicare Part
Drug Coverage