This information is for coverage beginning Jan. 1, 2020

Reliable, secure Part D prescription drug coverage

When you're covered by an Asuris Prescription Drug Plan, you can count on getting quick answers, friendly service and dependable coverage. With Asuris PDP plans, the benefits offer:

  • $0 prescription drug deductible available
  • Prescription deductible waived for Tier 1 and Tier 2 drugs
  • Additional gap coverage on Tier 1 available
  • Formulary that covers all classifications of Medicare-approved prescription drugs
  • Access to over 63,000 pharmacies nationwide, including most large chain pharmacies on select plans
  • Savings on 90-day supply of medication through convenient mail-order or retail pharmacies
  • Tools for finding the most effective and economical medications

Service area:
You must reside within our service area to be an Asuris member. Our service area includes Oregon and Washington.

Asuris Northwest Health is a Medicare Advantage and Part D plan with a Medicare contract. Enrollment in Asuris Northwest Health depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

Network pharmacies
Our pharmacy network has more than 63,000 participating pharmacies nationwide, including major retail chains, independent pharmacies and mail order. Show your Asuris ID card at a participating pharmacy and the pharmacy will handle the paperwork--you only pay your applicable copay or coinsurance amount. You must use network pharmacies to access your prescription drug benefit, except under nonroutine circumstances (quantity limitations and restrictions may apply).

Find a pharmacy near you:

Mail order
Using a mail-order option is a convenient way to fill your prescriptions. Your medications are delivered to your location of choice with free standard shipping.

With mail order, or a retail network pharmacy, you pay two times your copay for up to a 90-day supply of preferred and nonpreferred generics, or 2.5 times your copay for up to a 90-day supply of preferred and nonpreferred brand-name drugs.

Contact your pharmacy, or call 1 (844) 765-6825 (TTY users call 711), to find if your medications are available via mail-order.

To register, or place an order, choose one of our contracted mail-order providers below:

Drug Formulary
Search our formulary to find which prescription drugs are covered:

Other useful information regarding our formulary:

  • Transition policy (PDF): This policy gives new and current members information about medications that may no longer be on our formulary, or have new prior-authorization restrictions.
  • View coverage determination information, including formulary exceptions, prior authorizations and quantity limits for the Basic plan, Saver plan or Enhanced plan.

Extra Help
Extra Help, also called Low-Income Subsidy (LIS), is a Medicare program to help people with limited income and resources pay for their Medicare prescription drugs, premiums, deductibles, copays and coinsurance. Many people do not realize that they are eligible for this benefit. To see if you qualify for the Extra Help low-income subsidy, call any of the following:

  • Medicare: 1 (800) MEDICARE (1-800-633-4227). TTY 1 (877) 486-2048. Offices are open 24 hours a day, seven days a week.
  • Social Security: 1 (800) 772-1213. TTY 1 (800) 325-0778. Offices are open from 7:00 a.m. to 7:00 p.m., Monday through Friday.
  • Your state Medicaid office

View the monthly plan premiums for Extra Help on the Low-Income Subsidy premium chart (PDF).

Best Available Evidence for Low-Income Subsidy eligibility
Asuris follows the Best Available Evidence (BAE) guidelines that are outlined by the Centers for Medicare & Medicaid Services.

Quality improvement and utilization management
Asuris works hard to provide quality programs for our members. We're here to help ensure that medication options for our members are appropriate, safe and effective. We do concurrent drug utilization reviews and safety initiatives to give our members the best possible health benefits from their medications, while lowering risks for adverse events, medication errors, drug interactions or therapy duplications. We base our medication policies and procedures on careful review of scientific information and input from practicing physicians. Our ultimate goal is to enhance health outcomes with improved medication use for our members.

Medication Therapy Management
The Medication Therapy Management (MTM) Program helps you get the best results with your medications while keeping your costs down. Through MTM, a pharmacist will review all your medications and provide the extra attention you need to keep your medications on the right track. The MTM program is provided at no additional cost to you and is not considered a benefit.

MTM Services
Through the MTM program, you may receive the following services:

Comprehensive Medication Review (CMR)

  • A pharmacist will meet with you face-to-face or via phone to review all your medications for problems and help to organize your medication schedule. They may also recommend lower cost alternatives to your medications.
  • Following the CMR, you will receive a Medication Action Plan and Personal Medication List.
  • Estimated Time to Complete: 15 - 30 minutes

Targeted Medication Review (TMR)

  • Your medications will be reviewed every 3 months to look for any serious concerns related to your medications. A pharmacist will reach out to you if a serious concern is found.

Prescriber Consult

  • A pharmacist will work with your doctor(s) to resolve any concerns or problems found with your medications.

View the MTM program flyer (PDF) for more information, or contact Customer Service.

With Asuris, you have several options when applying for coverage. Consider this important information before applying:

Timelines for enrollment
Individuals may enroll in a Medicare Advantage or stand-alone prescription drug plan only during specific times of the year. Any Medicare-eligible individual may enroll during the Annual Enrollment Period, beginning October 15 through December 7, for coverage beginning the following January, or you may be eligible to enroll at other times including:

  • Initial Coverage Election Period (ICEP): This is the period when you first become eligible for Medicare. If you are about to turn 65, you can enroll up to three months before to three months after the month you turn 65.
  • Special Election Period (SEP): You may be granted a SEP by Centers for Medicare and Medicaid Services (CMS) to change plans outside of the Annual Election Period or Initial Coverage Election Period. Special Election Periods are time sensitive. Some examples of life events that may qualify for a SEP include but are not limited to:
    • You receive Extra Help.
    • You moved out of the service area.
    • You leave coverage from your employer or union.

Get more information about eligibility and enrollment.

Individual eligibility
Your eligibility is guided by the following:

  • Individuals must have Parts A and B, Part A only, or Part B only, to enroll in a stand-alone prescription drug plan.
  • You do not have end-stage renal disease (ESRD). Some exceptions may apply.
  • You live in our service area.

Medicare premium payment
You must continue to pay your Medicare Part B premium, unless Medicaid or another third party pays it.

Part D enrollment with a Medicare Advantage plan
If you are enrolled in a Medicare Advantage plan with prescription drug coverage, you must receive your Medicare Prescription Drug Benefit through that plan. You cannot add a stand-alone Medicare Part D plan to a Medicare Advantage plan.

Apply over the phone
Call 1 (844) 278-7472 from 8:00 a.m. to 5:00 p.m., Monday through Friday. From October 15 through December 7, we offer extended telephone hours. Our Medicare specialists will walk you through the process.

Apply by mail or fax
Download, print and complete our enrollment application. Mail or fax, using these instructions:

Mail or fax your enrollment and automatic bank deduction forms
Asuris Medicare Script
P.O. Box 1827
Medford, OR 97501

Fax forms to 1 (888) 335-2988. If you fax your forms, you do not need to mail them as well.

Applications must be RECEIVED in our office by December 7 if you're enrolling during the Annual Enrollment Period.

Other questions about applying?
Call us at 1 (844) 278-7472. Our hours are 8:00 to 5:00 p.m., Monday through Friday.

Enrollment through CMS
Medicare beneficiaries may also enroll in Asuris through the Medicare Online Enrollment Center located at http://www.medicare.gov.

Grievances

A grievance is any complaint you make about us or one of our plan providers. This does not involve payment or coverage disputes.

Examples of grievances include:

  • The customer service you receive
  • Waiting too long on the phone, waiting room, in the exam room or when getting a prescription
  • The length of time required to fill a prescription or the accuracy of filling a prescription
  • The quality of care you received from a provider or facility

Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling Customer Service. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form (PDF) and send it to us with your grievance form (PDF).

We must notify you of our decision about your grievance within 30 calendar days after receiving your grievance.

Contact information
Medicare Advantage/Medicare Part D
Appeals and Grievances
PO Box 1827
MS: B32AG
Medford, OR 97501

Oral coverage decision requests
1 (800) 541-8981

To request or check the status of a redetermination (appeal):
1 (866) 749-0355

Fax numbers
Appeals and grievances: 1 (888) 309-8784
Prescription coverage decisions: 1 (888) 335-3016

Visit the Forms tab for documents that will aid you in the coverage decision, appeal and grievance process.

Coverage decisions
A coverage decision is a decision we make about what we'll cover or the amount we'll pay for your medical services or prescription drugs.

Examples of coverage decisions include:

  • Formulary exceptions*
  • Copayment tiering exceptions*
  • Requests to find out if a medical service or procedure is covered

We respond to pharmacy requests within 72 hours for standard requests and 24 hours for expedited requests.** We respond to medical coverage requests within 14 days for standard requests and 72 hours for expedited requests. Coverage decision requests can be submitted by you or your prescribing physician by calling us or faxing your request. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form (PDF) and send it to us with your prescription coverage determination form (PDF).

*If you are asking for a formulary or tiering exception, your prescribing physician must provide a statement to support your request. You cannot ask for a tiering exception for a drug in our Specialty Tier. In addition, you cannot obtain a brand-name drug for the copayment that applies to the generic drug.

**If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or through a phone call to us) that he or she agrees that waiting 72 hours could seriously harm your life, health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician's support, we will decide if your health condition requires a fast decision.

Appeals

An appeal is any complaint you make when you want us to reconsider a decision we have made about your medical or Part D prescription drug benefits.

Examples of appeals include:

  • Our decision not to cover a drug, vaccine or other medical or Part D benefit
  • Our decision not to reimburse you for a medical service or Part D drug that you paid for
  • Our denial of a coverage decision

Appeals must be filed within 60 days of the payment or coverage denial. You must send an appeal to us in writing, including a signature. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form (PDF) and return it to us, along with a coverage redetermination form (PDF). We must notify you of the outcome of your appeal within seven calendar days after receiving your appeal. For more information about the medical and prescription appeal process, refer to your Evidence of Coverage in the section titled, "What to do if you have a problem or complaint."

Rights and responsibilities

Your rights and responsibilities regarding disenrolling

  • You must continue to use network pharmacies until you are disenrolled from our plan to receive prescription drug coverage under our formulary.
  • You have the right to make a complaint if we ask you to leave our plan.
  • You may only disenroll or switch prescription drug plans under certain circumstances.

    Annual Enrollment Period (AEP) (October 15-December 7)
    The Annual Election Period runs from October 15 through December 7 each year. During this time Medicare beneficiaries may change prescription drug plans, change Medicare Advantage plans, return to Original Medicare, or enroll in a Medicare Advantage plan for the first time. Coverage for enrollment changes takes effect on January 1.

    Open Enrollment Period (January 1-March 31)
    You can use this time period to return to your Original Medicare benefits offered by the federal government. You may also enroll in a stand-alone prescription drug plan.

    April 1-October 14
    Between April 1 and October 14 each year you will not be able to switch coverage. This time is often referred to as the "lock-in" period, unless you qualify under a special enrollment circumstance. During this period, you generally must stay with your current coverage until January 1, when any new coverage you choose, between October 15 – December 7, begins.

    Special Enrollment Period (SEP)
    Even if you didn't recently become eligible for Medicare, some exceptions allow you to enroll in a prescription drug plan or Medicare Advantage plan any time during the year. Examples of special enrollment circumstances include, but are not limited to individuals:
  • Who were enrolled in a plan and recently moved
  • Who entered a nursing home
  • Who are eligible for both Medicare and Medicaid
  • With low income
  • Who are disenrolling from an employer group health plan
  • Who involuntarily lost creditable prescription drug coverage

Disenrollment requests are always subject to eligibility for a qualifying election period and must be submitted in writing (such as moving outside of the service area, obtaining group coverage, enrolling in a MAPD plan with another carrier, LIS, etc).

  • Disenrollment requests received outside of a qualifying election period will not be honored.

Written requests for disenrollment should be faxed or mailed with the following information:

  • Signature of member or authorized representative
  • Member ID number
  • Contact phone number
  • Reason for disenrollment request

Send written requests to:
Attn: Membership Accounting, M/S B32M
P.O. Box 1827
Medford, OR 97501-0143
Fax: 1 (888) 335-2988

Note: Disenrollment requests are generally effective the first of the month following the receipt of the request.

Our rights and responsibilities upon your disenrollment
We will let you know, in writing, the date your coverage ends.

We have the right to disenroll you for the following reasons:

  • You are no longer eligible for Medicare Part A and/or B or Medicare prescription drug coverage
  • If we are no longer contracting with Medicare or we leave your service area
  • You move out of our service area
  • You materially misrepresent third-party reimbursement
  • You fail to pay your plan premium
  • You provide fraudulent information when you enroll or let someone else use your enrollment card to get covered services

Additional rights
To obtain information on the aggregate number of grievances, appeals and exceptions filed with the plan you may contact Customer Service.

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Last updated 10/01/2019
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