Learn more about Aspire Health Plan’s Prescription Drug Coverage.
2016 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:
2017 Interactive Formulary
To search for a specific pharmacy, check out our 2017 Interactive Pharmacy Directory.
For a detailed description of our Out-of-Network Pharmacy rules, check out our Evidence of Coverage.
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 2016 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 fewer 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 fewer 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. You can view a copy of our 2017 Part D Transition Letter PDF.
Aspire Health Plan offers a comprehensive Medication Therapy Management (MTM) program for our members who meet the following criteria:
- Having a minimum of three chronic disease states from one of the following conditions: Chronic Heart Failure (CHF), Diabetes, Dyslipidemia, Mental Health-Depression, Alzheimer’s Disease, and Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD).
- Six or more maintenance medications for chronic conditions
- Likely to incur annual drugs costs that exceed $3,919
The MTM program is designed to help members who meet these criteria get the most from their medicines. Specially trained pharmacists work closely with participants and their doctors to solve any problems related to medicines and to help them get the best results.
Members who meet criteria will be sent an introduction letter which describes the MTM program and provides information on how to schedule a phone appointment with the MTM pharmacist. Members, who reside in a long-term care facility, will be automatically enrolled and sent information describing the MTM program.
During your phone consultation, your MTM pharmacist will review your medicines and answer any questions you may have. You’ll get a list of all your medicines, with detailed advice on how to get the most out of them. Your MTM pharmacist will be available to help you throughout your treatment.
This program is not considered a Medicare benefit. It is available at no additional fee to those who meet the limited eligibility criteria listed above. The program is voluntary and participants can disenroll at any time.
For additional information on our MTM program, feel free to call us toll-free at
866-632-7958 (toll free)
866-706-4757 (toll free TTY)
24 hours a day, 7 days a week
For more information on the Medication Therapy Management Program please review the following documents:
Are you an Aspire Health Advantage Value (HMO), Aspire Health Advantage (HMO) or Aspire Health Advantage 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. You also may call:
- Our Member Services department at 831-574-4938 (local), 855-570-1600 (toll free), 831-574-4940 (local TTY), 855-382-7195 (toll free TTY), 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
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.
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.
- visit http://www.medicare.gov/Pubs/pdf/11324.pdf
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, copayments, 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.
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.