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 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.
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.
2024 Part B Prior Authorization Drug List (PDF): English
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.
2024 Part B Step Therapy Updates (PDF): English
Part B Drug Clinical Policies
Beovu (brolucizumab) Clinical Policy
Evenity (romosozumab-aqqg) Clinical Policy
Eylea (aflibercept) Clinical Policy
Hyaluronic Acid Derivatives Clinical Policy
Infliximab Products Clinical Policy
Lemtrada (alemtuzumab) Clinical Policy
Ocrevus (ocrelizumab) Clinical Policy
Prolia (denosumab) Clinical Policy
Ranibizumab Products Clinical Policy
Rituximab Products Clinical Policy
Tysabri (natalizumab) Clinical Policy
Vabysmo (faricimab-svoa) Clinical Policy
Zilretta (triamcinolone acetonide ER injection) Clinical Policy
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 Online Drug Formulary
To search for a specific pharmacy, view our Interactive Online Pharmacy Directory.
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.
2024 Step Therapy Updates (PDF): English
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.
2024 Prior Authorization Updates (PDF): English
For a detailed description of our out-of-network pharmacy rules, check out our Evidence of Coverage documents located on our 2024 Plan Documents page.
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:
Apply for extra help online at ssa.gov
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.
For members who are institutionalized or in a long-term care facility, an appointed representative can provide a copy of the following BAE examples:
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.
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:
To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:
Use these Personal Medication List (PML) that can help you and your healthcare providers keep track of the medications you are taking.
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.
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:
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.
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:
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
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:
Disposal in Household Trash
If these programs are not available in your area, place the drugs in the trash by following these steps:
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 http://toxics.usgs.gov/pubs/FS-027-02/pdf/FS-027-02.pdf
Safe Disposal of Prescription Medication (PDF): English | Español
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 Online Drug Formulary
To search for a specific pharmacy, view our Interactive Online Pharmacy Directory.
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.
2023 Step Therapy Updates (PDF): English
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.
2023 Prior Authorization Updates (PDF): English
For a detailed description of our out-of-network pharmacy rules, check out our Evidence of Coverage documents located on our 2023 Plan Documents page.
Future Formulary Changes (PDF)
Future Formulary Changes (Effective 2/1/2023)
Future Formulary Changes (Effective 3/1/2023)
Future Formulary Changes (Effective 4/1/2023)
Future Formulary Changes (Effective 5/1/2023)
Future Formulary Changes (Effective 6/1/2023)
Future Formulary Changes (Effective 7/1/2023)
Future Formulary Changes (Effective 8/1/2023)
Future Formulary Changes (Effective 9/1/2023)
Future Formulary Changes (Effective 10/1/2023)
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 (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 medicare.gov.
You also may call:
Apply for extra help online at ssa.gov
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.
For members who are institutionalized or in a long-term care facility, an appointed representative can provide a copy of the following BAE examples:
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 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.
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:
To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:
Use these Personal Medication List (PML) that can help you and your healthcare providers keep track of the medications you are taking.
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.
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:
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:
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
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:
Disposal in Household Trash
If these programs are not available in your area, place the drugs in the trash by following these steps:
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 http://toxics.usgs.gov/pubs/FS-027-02/pdf/FS-027-02.pdf
Prospective Members
Toll-free: (866) 798-1530 (TTY 711)
Current Members
Toll-free: (855) 570-1600 (TTY 711)
Local: (831) 574-4938 (TTY 711)
Hours
October 1 to March 31
7 Days a Week
8 a.m. to 8 p.m. PT
April 1 to September 30
Monday – Friday
8 a.m. to 8 p.m. PT
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Aspire Health Plan is a Medicare Advantage HMO plan sponsor with a Medicare contract. Enrollment in Aspire Health Plan depends on contract renewal.
Medicare beneficiaries may also enroll in Aspire Health Plan 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 Plan 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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Page last updated: November 30, 2023