Pharmacy and Related Medical Policies

The following are policies referenced and used in medical necessity determinations. All Medical and Pharmacy policies, when relevant, can be applied to any utilization review.

Policies related to prescription drug benefits for self-administered drugs are applicable when PreferredOne is performing this utilization management function on behalf of the member’s pharmacy benefits manager (PBM). PreferredOne performs this function on behalf of the PBM ClearScript for members on certain PreferredOne plans who utilize ClearScript as their PBM. PreferredOne may also perform this function on behalf of other PBMs (e.g., Express Scripts), at their direction.

Benefits must be available for health care services. Health care services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. See policy MP/C009.

New FDA approved provider administered drugs may be non-covered until a full internal review has occurred, which may take up to 180 days. See policy PP/R001.

Medications that are being used outside their FDA approved dose, indication, or frequency require review in accordance with our off-label policy PP/O001.

All PreferredOne policies are subject to review and PreferredOne reserves the right to make updates to these policies at any time.

The following are policies referenced and used in medical necessity determinations. All Medical and Pharmacy policies, when relevant, can be applied to any utilization review.

Benefits must be available for health care services. Health care services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. See policy MP/C009.

New FDA approved provider administered drugs may be non-covered until a full internal review has occurred, which may take up to 180 days. See policy PP/R001.

Medications that are being used outside their FDA approved dose, indication, or frequency require review in accordance with our off-label policy PP/O002.

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.