Aspire Health Plan (HMO and HMO-POS) Comprehensive Formulary 2019

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Definition of a Formulary

A formulary is a list of covered drugs selected by your plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Your plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. This formulary may change during the year.

Your plan covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be safe and effective as brand name drugs.

How to use the On-Line Formulary Search Tool
  • To search the formulary you may do so by selecting a specific drug or by selecting a category of drugs.
    • To Search by a specific drug: Begin your search by entering a drug name in the “Drug Name” box and selecting the “search” button.
    • To search by a category of drugs: Begin your search by selecting a therapeutic category from the drop down list. After you have selected a therapeutic category, you may select the “search” button or if you would like to be more specific you may then select the therapeutic class from the drop down list and then select the “search” button to see the results. The therapeutic class selection is optional and not required to see the results.
  • You can search for another drug by selecting “New search” option.
  • The results may not display a complete list of all formulary alternatives covered by your plan for the drug you have selected.
How do I request an exception to the Formulary?

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.


Page Last Updated: 10/01/2019

*Disclaimer: All drugs and utilization management edits (quantity dispensing limits, Step Therapy, and prior authorization requirements) included on the formulary are not necessarily covered or apply to each member’s prescription drug benefit plan. The inclusion of a drug on this list does not imply coverage under all plans. Coverage of listed products will be subject to limitations of the prescription drug benefit plan design. Utilization management edits can also be unique to individual prescription drug benefit plan design. Members should consult their prescription drug benefit manual or contact a customer service representative to determine specific coverage.