Learn more about Aspire Health Plan’s prescription drug coverage.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 your medications, please visit our Formulary: 2021 Interactive Formulary
Extra Help for Part D drugs
Are you an Aspire Health Value (HMO), Aspire Health Advantage (HMO) or Aspire Health 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, or 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 1-800-MEDICARE (1-800-633-4227) (toll free), or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, seven days a week. Or visit the Medicare web site.
You also may call:
- Our Member Services department at 831-574-4938 (local), 855-570-1600 (toll free), (TTY: 711), seven days a week, 8 a.m. to 8 p.m. or call:
- Social Security at 1-800-772-1213 (toll free) between 7 a.m. and 7 p.m., Monday through Friday, or 1-800-325-0778 (toll-free TTY for the hearing/speech impaired). Or visit the Social Security web site.
- Your state Medi-Cal office
- Apply for extra help online
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 to 831-574-4939 (local), 855-519-5769 (toll free)
For more information on Low Income Subsidy and BAE, please visit the following websites (By clicking on the links below you will be leaving our website):
- The Best Available Evidence (BAE) Policy on the Medicare website.
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.
If you rely on regular or long-term medications, there may be a better way to get your prescriptions filled. MedImpact Direct is home delivery and a smart, simple way for you to get prescriptions delivered to your door. Mail order pharmacy. And, you save money on your prescription co-pays with our 3 months supply for two co-payments.
Medication Therapy Management (MTM)
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 ALL of the following criteria:
- Have at least 3 of the following conditions or diseases: Chronic Heart Failure, Diabetes, Dyslipidemia, Hypertension, Asthma, or Chronic Obstructive Pulmonary Disease AND
- Take at least 8 covered Part D medications, AND
- Are likely to have medication costs of covered Part D medications greater than $4,376 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 by pharmacies operated by SinfoníaRx. 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:
- Medication Action Plan (MAP): The action plan 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.
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 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.Evidence of Coverage – Aspire Health Advantage (HMO) PDF
Evidence of Coverage – Aspire Health Plus (HMO-POS) PDF
Evidence of Coverage – Aspire Health Value (HMO) PDF
Evidence of Coverage – Aspire Health Group Plus (HMO-POS) PDF
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 your medications, please visit our Formulary:
– Future Formulary Changes (Effective 03/01/2021)
– Future Formulary Changes (Effective 05/01/2021Request for Medicare Prescription Drug Coverage Determination PDF | Solicitud para la determinación de cobertura de medicamentos recetados de medicareSpanish (en español PDF)
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, click here.
You have the right to request an exception to the Aspire Health Plan Drug Formulary. To learn more on the types of exceptions, click here.
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
- For those members who are new or who were in the plan last year:
To ask for a temporary supply, call Member Services at (855) 570-1600. 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.
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.