2021 Formulary – Aspirus Health Plan

ESSENTIAL RX AND ELITE RX 2021 FORMULARY (LIST OF COVERED DRUGS)

Formulary (List of Covered Drugs) (PDF) (updated 12/1/21)
Prior Authorization Criteria (PDF) (updated 12/1/21)
Step Therapy Criteria (PDF) (updated 4/1/21)
Aspirus Formulary Exception Criteria (PDF) (updated 9/7/21)
Part B Medical Injectable Drug Authorization List (PDF) (updated 6/14/21)

See what you pay in each tier

Part D information

Prescription drug claim form (PDF)
Request for Medicare Prescription Drug Coverage determination form (PDF)
Request for Redetermination of Medicare Prescription Drug Denial Form (PDF)
Prescription Drug Transition Policy (PDF)
Medication Therapy Management (MTM)
Available to all Medicare-eligible members who meet program criteria. While not a part of a prescription drug benefit, it is a Medicare designed program sponsored by Aspirus Health Plan.

Do you qualify for Extra Help with your prescription drug costs?

If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium with Aspirus Health Plan will be lower than what it would be if you did not get Extra Help from Medicare. The amount of Extra Help you get will determine your total monthly plan premium as a member of our plan.

Aspirus Health Plan premium includes coverage for both medical services and prescription drug coverage.

If you aren’t getting Extra Help, you can see if you qualify by calling:

1-800-MEDICARE (1-800-633-4227), TTY/TDD users 1-877-486-2048 (24 hours a day/ days a week)
Your state Medicaid Office, or
The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778.

You can also find information on the Medicare.gov and Social Security Administration websites (external sites).

Your level of Extra Help	Elite Rx
100%	$52.70
75%	$59.30
50%	$65.80
25%	$72.40

Mail order pharmacy program

Aspirus Health Plan Medicare members may order up to a 90 day supply on certain medications to be delivered by mail through Express Scripts. Besides convenience, benefits include free home delivery and 24/7 access to a pharmacist.

Choose one of these ways to start receiving your medications at home:

Call in your prescriptions. Call 1-877-567-6320 (toll free) to speak with an Express Scripts patient care advocate who can help you get started with Home Delivery. Hours of operation are 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-716-3231 (toll free). When you call, please have your ID number (found on your member ID card), your doctor’s name and phone number, and a list of your current medications or medicine containers.
Visit Express Scripts online. Go to express-scripts.com (external site) and follow the prompts.
Ask your provider to contact Express Scripts Mail Order.

H6874_50261_2121
10/2020

Medicare Plans