Drug coverage

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

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 BAE Policy on the Medicare website.
• http://www.medicare.gov/your-medicare-costs/help-paying-costs/save-on-drug-costs/save-on-drug-costs.html

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. 2020 Mail order pharmacy. And, you save money on your prescription co-pays with our 3 months supply for two co-payments.

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:

1. Have at least 3 of the following conditions or diseases: Chronic Heart Failure, Diabetes, Dyslipidemia, Hypertension, Asthma, or Chronic Obstructive Pulmonary Disease 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 $4,255 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.

To obtain a blank copy of the Personal Medication List (PML) that can help you and your health care providers keep track of the medications you are taking, click here {link to blank PML provided by plan sponsor}.

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.

For a detailed description of our Out-of-network pharmacy rules, check out our Evidence of Coverage.

Search for a Provider or view our PDF directory

To search for a specific pharmacy, check out our 2020 Interactive Pharmacy Directory.

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:

2020 Interactive Formulary

2020 Bilingual Formulary PDF

Announcement: FDA Recall of Ranitidine (Zantac) products

Future Formulary Changes_Effective 5/1/2020

Future Formulary Changes_Effective 6/1/2020

Future Formulary Changes_Effective 7/1/2020

Future Formulary Changes_Effective 8/1/2020

Future Formulary Changes_Effective 9/1/2020

Future Formulary Changes_Effective 10/1/2020

Future Formulary Changes_Effective 12.1.20

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, click here.

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, click here.

As a new or continuing member in one of our plans, you may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception (which is a type of coverage determination) to get coverage for the drug. While you and your doctor determine the right course of action, we may cover the non-formulary drug in certain cases during the first 90 days of new membership or for existing members’ first 90 days of the 2020 plan year.

For each of the drugs that is not on our formulary or that we have coverage restrictions or limits on, we will cover one temporary 30-day supply (unless the prescription is written for 30-days) when you go to a network pharmacy and the drug is otherwise a “Part D drug.” After the 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a new member who is a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for 30-days), with refills provided, during your first 90 days of membership. If you are past the first 90 days of new membership in our plan, we will cover a 31-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception or coverage determination.

Other times, we will cover a temporary 30-day transition supply (unless the prescription is written for fewer days) are when you enter or leave a long-term care facility, are discharged from a hospital, leave a skilled nursing facility, cancel hospice care, or when you are discharged from a psychiatric hospital on a specialized medication regimen.

As you are transitioning into our plan, your prescription drug coverage will not be disrupted.

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.