PreferredOne 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, PreferredOne will disclose this information to contracted healthcare providers no less than 45 days prior to the implementation of any new or updated policy or PA list changes.
PreferredOne reserves the right to amend non-material updates to the PA list or any policy at any time without disclosure.
Click on the “Medical Policy and Pharmacy Policy Future Updates” link to the right for the latest updates.
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.
Important note: Before using these policies, read Coverage Policy Usage Notice.
Before services are rendered, read Prior Authorization List & Policy Usage Notice,
Site of Care Policy Information.
Before services are rendered, read Prior Authorization List & Policy Usage Notice.
PreferredOne has a pre-payment, post service claim edits (PSCE) program on specific medically administered medications. For more information, click here.
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.
For Hyaluronic Acid Derivatives, Euflexxa, Synvisc, and Synvisc-One are covered without prior authorization when administered according to their FDA label for dose, duration, and indication.
All other hyaluronic acid derivatives are considered non-preferred and excluded from coverage.
All infliximab products require prior authorization and are allowed up to 140 billable units per claim.
All rituximab products require prior authorization and are allowed up to 400 billable units during a 6-month rolling period.
Botox and Dysport do not require prior authorization, however, claims are reviewed for appropriate diagnosis.
A list of allowed diagnosis codes can be found here.
All infliximab, rituximab, and botulinum toxin products are subject to review for appropriate diagnosis, dose, frequency, and duration based on the indication provided.
Drugs and services excluded from coverage that are on the Pharmacy Investigative List are here.
The following medical drugs are excluded from coverage and are on the Cost Benefit List.
- Cortrophin Gel (repository corticotropin)
- H.P. Acthar Gel (repository corticotropin) J0800
- Makena (hydroxyprogesterone caproate) J1726 (generic J1729 can be used without prior authorization)
- Quzyttir (cetirizine hydrochloride injection) J1201
- Susvimo (Ranibizumab, intravitreal implant) J2779
For Hyaluronic Acid Derivatives, Euflexxa, Synvisc, and Synvisc-One are covered without prior authorization
when administered according to policy and are subject to post-service claim edits.
All other hyaluronic acid derivatives are considered non-preferred and excluded.
Drugs and services excluded from coverage that are on the Pharmacy Investigative List are here.
Certain medical drugs are excluded from coverage and can be found on the Cost Benefit List.
For other preferred, non-preferred, and non-covered products, see a summary here.
For other preferred, non-preferred, and non-covered products, see a summary here.