Aspirus Health Plan updates its clinical policies and prior authorization (PA) list regularly and reserves the right to amend the prior authorization list and/or policies at any time.
If material amendments are made to any policy or PA list, Aspirus Health Plan will disclose this information to contracted healthcare providers no less than 60 days prior to the implementation of any new or updated policy or PA list changes.
Aspirus Health Plan reserves the right to amend non-material updates to the PA list or any policy at any time without disclosure.
Aspirus Health Plan has a pre-payment, post service claim edits (PSCE) program on medically administered medications.
Pre-payment claim edits verify that claims are paid in accordance with their allowable diagnosis, frequency, and maximum billable units consistent with the FDA label and/or an authoritative compendium recognized by the Medicare program.
For more information, see our Off-Label Policy here.
Any prior authorization determination from a medical necessity review is specific only to the drug being requested, unless stated otherwise, and is not a guarantee of payment or benefits.
For all medications billed under the member’s medical benefit, claims received for a dose, duration, and/or frequency exceeding what is recommended in Food and Drug Administration (FDA) labeling may be subject to review and could result in partial or denied payment.
Claims for excessive drug wastage will not be reimbursed.
Certain medical drugs are excluded from coverage and can be found on the Cost Benefit List.