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Aspire Health Medicare Advantage
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Medicare Part B Drug updates
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Aspire Health Plan’s Medicare Advantage Part B updates,
effective September 1, 2026, include the Step Therapy Drug List and
changes to prior authorization policies.
These updates outline preferred products, coverage requirements, and
evidence-based criteria to support appropriate use of
physician-administered drugs.
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Cologuard® Screening Program
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To help close
colorectal cancer screening gaps, Aspire Health has partnered with
Lifeline to mail Cologuard® at-home screening kits to eligible
members attributed to Montage Health or an independent physician.
Here are the next steps:
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- Within
the next couple of weeks, members/patients will receive a
Cologuard kit. Cologuard is an easy-to-use, noninvasive
screening test that can be used at home.
- The
ordering provider will communicate the Cologuard test result to
your patient. You will receive a copy of your patient’s result
by fax/EMR from Exact Sciences.
- Aspire
will reach out to your office to communicate with any members
who receive a positive result. A positive result should be
followed up with a colonoscopy.
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If your patient contacts you after receiving the
Cologuard kit, please explain that we placed the order so that the
patient can be screened for colon cancer. There will be $0 cost
to the patient for this test.
Patients with questions about completing the Cologuard test may
contact Exact Sciences Laboratories at (844) 870-8870, available 24
hours a day, 7 days a week.
You can find more information about Cologuard test
results here www.cologuardhcp.com/faq.
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Blue Shield and Anthem HMO
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2026 Provider Appointment
Availability Surveys
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The 2026 Provider
Appointment Availability Surveys are currently underway. These
surveys include a random selection of primary care and specialty care
providers, as required by the California Department of Managed Health
Care (DMHC).
If your office is contacted, the survey will ask for the
next available appointment date and time for a new patient. Depending
on the service being requested, this may include an in-person,
telephone, or video (telehealth) appointment. Please ensure your
staff is familiar with and follows the applicable appointment
availability standards when responding.
Timely access to care
is required under California law. To remain compliant, members must
be able to obtain appointments within the required timeframes and
have access to appropriate after-hours care and instructions.
Please review the Timely Access to Care Standards with
your office staff and ensure everyone is familiar with the
requirements.
Access Standards for
Medical Professionals and Ancillary Providers
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- Non-urgent
appointments for Primary Care (PCP): 10 business days
- Urgent
Care appointments not requiring prior authorization (PCP): 48
hours
- Non-urgent
appointments with Specialist Physicians (SCP): 15
business days
- Urgent
Care (that requires prior authorization) (SCP): 96
hours
- Non-urgent
appointment for ancillary services (for diagnosis or treatment
of injury, illness, or other health condition): 15
business days
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Access Standards for
After-Hours
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- Emergency
Care: Immediate Access to Emergency Care
- Urgent
Requests: Available 24 hours/7days.
Patient to reach a recorded message or live voice response
providing emergency instructions; and for non-emergent (urgent)
matters, a mechanism to reach a medical professional, or a
practitioner (non-MD) with information as to when to expect a
call back.
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Aspire Health Medicare Advantage,
Blue Shield HMO, and Anthem HMO
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CIM Pharmacy Prior Authorization
Updates
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To help streamline the pharmacy prior authorization
process, we've compiled several important reminders and recent
updates to the CIM Referral Manager. Highlights include required
information for submissions, guidance on standard versus expedited
requests, and new system enhancements such as NDC information,
maximum units per visit, and required document attachments.
Click
below to review the latest tips and system updates before submitting
your next pharmacy prior authorization request.
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Aspire Health Medicare Advantage and
Employee Health Plans
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Preferred Biosimilar Changes
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As part of Aspire Health Plan’s commitment to
high-quality, cost-effective care, we encourage the use of biosimilar
medications and have removed
Humira from the formulary.
The new preferred
biosimilar product is outlined in the document below.
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- Aspire
Health Plan (Medicare Advantage)
- Montage
Health Affiliates Employee Healthcare Plan
- Community
Hospital of the Monterey Peninsula Employee Healthcare Plan
- Collaborative
Employees Healthcare Plan
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Corrected Claims Submission
Requirements
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To help ensure corrected claims are processed accurately
and avoid unnecessary denials or delays, please review the
requirements for submitting corrected claims. This includes guidance
on required claim frequency codes, Document Control Numbers (DCNs), and
submission instructions for both electronic and paper claims.
Click
below to review the corrected claims submission requirements and help
ensure your claims are processed successfully.
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Epic Real-Time Prescription Benefit
(RTPB) Tool
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Electronic health records (EHRs) include built-in tools
that can be used at the time of pharmacy benefit medication ordering
to determine whether a medication is on formulary, what the patient
cost share will be, identify prior authorization requirements, and
review the formulary and/or lower-cost alternatives.
The Real-Time Prescription Benefit
(RTPB) tool has been available in Epic since 2020 for
both outpatient and inpatient providers. RTPB interacts in real time
with the payer’s systems to identify what the patient’s cost share
will be today if they were to pick up this medication from the
pharmacy. The quoted cost accounts for the patient's current benefit
phase (such as deductible, initial coverage, or catastrophic
coverage), which can affect what they pay. This feature helps
determine whether what you are prescribing is on formulary, identify
similar medications that are on formulary, and determine the member’s
cost share.
A Prescription Alternatives
pop-up window will automatically appear if the
initial medication is not on formulary and there are similar
medications that may be considered. Please note that this is not a
substitute for clinical judgment and not every medication presented
will be clinically appropriate for your patient.
Providers can also manually search for alternatives
using the Estimates / Patient Estimates
button.
Key benefits
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- View
whether a medication is on the patient’s formulary
- Identify
the patient’s cost-share tier before prescribing
- Compare
formulary alternatives to reduce out-of-pocket costs
- Prevent
delays and gaps in care by ensuring prescriptions ordered are
covered benefits and affordable for your patients
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Best
practice workflow
When starting a new medication:
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- Enter
the prescription before the patient leaves the visit
- Use the
RTPB tool to review cost and coverage details
- Discuss
expected out-of-pocket costs with the patient at the point of
care
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When RTPB is used, the estimated out-of-pocket cost
will also be included in the patient’s After Visit Summary (AVS).
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Aspire Health Medicare Advantage
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Aspire Direct Commercial HMO network
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You
are receiving this email because you are a provider contracted with
an Aspire Health Medicare Advantage or managed care commercial plan.
View
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© 2026 Aspire Health, All rights reserved.
Our mailing address is:
10 Ragsdale
Drive, Suite 101, Monterey, CA 93940
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