CurrentAspirus ArisePolicy N/A

Medical Injectable Drug Prior Authorization Request Form

Form and instructions for non-contracted providers to request prior authorization under the medical benefit from Aspirus Health Plan for injectable drugs; applies to providers submitting requests on behalf of Aspirus members.

Policy Summary

PayerAspirus Arise

PolicyMedical Injectable Drug Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeAdministrative — form/instruction update

Effective DateN/A

Next Review DateN/A

Key ActionNon-contracted providers must complete and fax the completed form with clinical documentation to 715-841-4322 before administering and billing for the drug.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2pages

715-841-4322fax

optionpre-determination

checkboxnetwork exception

Form Data and Authorization Criteria

Required form data elements

Information fields that the requester must provide to support authorization:

ALL of the following

Member Name
Member DOB
Aspirus Member ID#
Ordering Prescriber Name and NPI
Drug Requested

Policy Summary

PayerAspirus Arise

PolicyMedical Injectable Drug Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeAdministrative — form/instruction update

Effective DateN/A

Next Review DateN/A

Key ActionNon-contracted providers must complete and fax the completed form with clinical documentation to 715-841-4322 before administering and billing for the drug.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding Fields and Quantity

Required coding fields on formmixed

HCPCS Procedure Code	Field for HCPCS code associated with the injectable drug
NDC No	Field to capture the drug's NDC
ICD-10 code(s)	Diagnosis code(s) related to the drug request

inv-03: Number of Units Requested

Field nameNumber of Units Requested

Location on formLocated in the Coding/Drug request section after 'Drug Requested'

PurposeSpecify the quantity (units) of the injectable drug for which authorization is requested

Required?Listed among required form data elements for authorization support

Submission Requirements and Request Options

Prior Authorization

Prior Authorization Submission Requirement

Non-contracted providers must complete and fax the Medical Injectable Drug Prior Authorization Request Form with supporting clinical documentation to Aspirus Health Plan before administering and billing for the drug. Fax the completed form and clinical documentation to Aspirus at: 715-841-4322.

Fax: 715-841-4322
Use this form for medical benefit injectable drug prior authorization
Non-contracted providers: completion and fax required prior to administration and billing

Note

Network Exception Option

The form includes an option to request a network exception. Providers should indicate whether they are requesting a network exception by selecting Yes or No on the form.

Network exception option: Yes / No

Documentation Required

Pre-determination and Urgency

The form provides a checkbox to indicate this is a pre-determination request for a drug that does not have a coverage policy and includes fields to record the request date and select request urgency (Standard or Expedited). Providers should check the pre-determination box when applicable and select the appropriate urgency to ensure timely processing.

Pre-determination checkbox for drugs without a coverage policy
Request Date field
Request Urgency: Standard or Expedited

Defined Options on the Form

inv-07: A request for a drug that does not have a coverage policy

TermPre-determination request

DefinitionA request for a drug that does not have a coverage policy; form contains a checkbox to indicate this

Form fieldCheckbox: 'Check here if this is a pre-determination request for a drug that does not have a coverage policy'

Related actionRequestor selects Standard or Expedited request urgency when checking this box

inv-08: Network exception

TermNetwork exception

DefinitionAn option the requester can select to request an exception to use a non-network provider or facility

Form fieldQuestion: 'Are you requesting a network exception? Yes No' with selectable option(s)

PlacementLocated near the top of the form before drug and coding fields