Aspire Health Value (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Aspire Health Value (HMO) by Aspire Health Plan. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a California Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Aspire Health Value (HMO)(H8764-003) plan has a $400 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However, some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Aspire Health Plan will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Aspire Health Value
Plan ID: H8764-003
Provider: Aspire Health Plan
Plan Year:2023
Premium:$38.90
Deductible:$400
Initial Coverage Limit:$4660
Coverage Area:California
Similar Plan:H8764-001


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Abacavir
2NNA$18NANN
Abacavir And Lamivudine
2NNA$18NANN
Abelcet
4YNA$100NAYN
Abiraterone
5NA25%NA120/30YN
Abiraterone Acetate
5NA25%NA120/30YN
Acarbose
2NNA$18NA90/30NN
Accutane
2NNA$18NANN
Acebutolol Hydrochloride
2NNA$18NANN
Acetaminophen And Codeine Phosphate
2NNA$18NA4500/30NN
Acetazolamide
2NNA$18NANN
Acetic Acid
2NNA$18NANN
Acetylcysteine
2NNA$18NAYN
Acitretin
2NNA$18NANN
Actemra
5NA25%NAYN
Actemra Actpen
5NA25%NAYN
Acthar
5NA25%NA35/28YN
Acthib
3YNA$47NANN
Actimmune
5NA25%NAYN
Acyclovir
4YNA$100NANN
Acyclovir Sodium
2NNA$18NAYN
Adapalene
4YNA$100NANN
Adefovir Dipivoxil
2NNA$18NANN
Adempas
5NA25%NA90/30YN
Advair
2NNA$18NA60/30NN
Advair Hfa
3YNA$47NA12/30NN
Ajovy
3YNA$47NA/30YN
Ala-scalp
4YNA$100NANN
Alacort
2NNA$18NANN
Albendazole
5NA25%NANN
Albuterol Sulfate
2NNA$18NA1/30NN
Alclometasone Dipropionate
2NNA$18NANN
Alecensa
5NA25%NA240/30YN
Alendronate Sodium
1NNA$9NA4/28NN
Aliskiren
2NNA$18NANN
Alosetron Hydrochloride
5NA25%NANN
Alprazolam
2NNA$18NA90/30NN
Altavera
2NNA$18NANN
Alunbrig
5NA25%NAYN
Alyacen 1/35
2NNA$18NANN
Alyq
2NNA$18NA60/30YN
Amabelz
2NNA$18NAYN
Amantadine Hydrochloride
2NNA$18NANN
Ambisome
5NA25%NAYN
Amethia
2NNA$18NA91/84NN
Amiloride Hydrochloride And Hydrochlorothiazide
2NNA$18NANN
Amiloride Hydrocloride
2NNA$18NANN
Amiodarone Hydrochloride
2NNA$18NANN
Amitriptyline Hydrochloride
2NNA$18NANN
Amlodipine And Benazepril Hydrochloride
1NNA$9NANN
Amlodipine And Olmesartan Medoxomil
2NNA$18NANN
Amlodipine And Valsartan
2NNA$18NANN
Amlodipine Besylate
1NNA$9NANN
Amlodipine Besylate And Benazepril Hydrochloride
1NNA$9NANN
Ammonium Lactate
2NNA$18NANN
Amoxapine
4YNA$100NANN
Amoxicillin
2NNA$18NANN
Amoxicillin And Clavulanate Potassium
2NNA$18NANN
Amphotericin B
2NNA$18NAYN
Ampicillin
2NNA$18NANN
Ampicillin And Sulbactam
2NNA$18NANN
Ampicillin Sodium And Sulbactam Sodium
2NNA$18NANN
Anagrelide
2NNA$18NANN
Anastrozole
1NNA$9NANN
Apraclonidine Ophthalmic
2NNA$18NANN
Aprepitant
2NNA$18NAYN
Apri
2NNA$18NANN
Aptivus
5NA25%NANN
Aranelle
2NNA$18NANN
Aripiprazole
5NA25%NA90/30NY
Aristada
5NA25%NA/56NN
Aristada Initio
5NA25%NA/365NN
Armodafinil
2NNA$18NA30/30YN
Arnuity Ellipta
3YNA$47NA30/30NN
Ascomp With Codeine
2NNA$18NA180/30YN
Asenapine
2NNA$18NA60/30NN
Ashlyna
2NNA$18NA91/84NN
Atenolol And Chlorthalidone
2NNA$18NANN
Atomoxetine
2NNA$18NA30/30NN
Atovaquone
2NNA$18NANN
Atovaquone And Proguanil Hydrochloride Pediatric
2NNA$18NANN
Atrovent
4YNA$100NA2/28NN
Aubra Eq
2NNA$18NANN
Austedo
5NA25%NA120/30YN
Aviane
2NNA$18NANN
Avonex
5NA25%NA1/28YN
Ayvakit
5NA25%NA30/30YN
Azathioprine
2NNA$18NAYN
Azelastine Hcl Nasal
2NNA$18NA30/25NN
Azelastine Hydrochloride
2NNA$18NA30/25NN
Azithromycin
2NNA$18NANN
Azopt
2NNA$18NANN
Aztreonam
2NNA$18NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H8764-003

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $400. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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