A Formulary outlining the covered drugs and associated limitations, along with criteria used for prior authorization is available:
Express Scripts, Inc. (ESI) is the pharmacy benefit manager for Aspirus Health Plan Medicare Advantage beneficiaries. All covered new and refill prescriptions should be processed through ESI.
ePA is the preferred method to submit Prior Authorization requests to Express Scripts for pharmacy benefit drugs. Providers may use ePA through ExpressPAth, Sure Scripts, CoverMyMeds or through the Electronic Health Record.
Express Scripts coverage review can be reached by phone at 1-877-558-7521 or by fax at 1-877-251-5896.
Request for Medicare Prescription Drug Coverage Determination (PDF)
Care Continuum, a subsidiary of Express Scripts, reviews Medical Drug Prior Authorization requests for all Aspirus Health Plan Medicare Advantage plans.
Non-participating providers should send the Medical Injectable Drug Prior Authorization Request Form (PDF)
Providers that received a claim denial due to no authorization in place will continue to work through the provider claims appeal process using the Provider Claim Reconsideration Request Form (PDF).
Medication Therapy Management Program Information
Prescription Drug Transition Policy (PDF)
Express Scripts Mail Order Pharmacy can be reached by phone at 1-866-544-7950 or by fax at 1-800-837-0959. e-Prescribing: Express Scripts Home Delivery Pharmacy
Pharmacy Network – Aspirus Health Plan Medicare members have access to a preferred pharmacy network, including Aspirus pharmacies. Costs for some drugs may be less at pharmacies in this preferred network. Find pharmacies using our online pharmacy directory.
March 2022 Pharmacy & Therapeutics Committee Decisions (PDF)
January 2022 Pharmacy & Therapeutics Committee Decisions (PDF)
November 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
September 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
June 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
April 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
March 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
January 2021 Pharmacy & Therapeutics Committee Decisions (PDF)