CurrentAspirus ArisePolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Describes the process and form for Medicare enrollees (or their authorized representative/prescriber) to request a redetermination (appeal) of a denied prescription drug coverage/payment decision by Aspirus Health Plan.

Policy Summary

PayerAspirus Arise

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribers may submit an appeal on behalf of the enrollee; a prescriber supporting statement enables expedited (72-hour) review when waiting 7 days could seriously harm the enrollee.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daystimeframe to request a redetermination

72 hoursexpedited decision target

7 daysstandard wait before expedited considered

1-855-931-4857fax to submit

aspirushealthplan.com/medicare/website

Redetermination Request Requirements

Redetermination request requirements

Procedure and required information to request redetermination of a denied prescription drug coverage/payment decision.

Who may request: enrollee, enrollee's prescriber, or an authorized representative with documentation (e.g., naming a representative).

Timeframe: Request must be submitted within 60 days of the Notice of Denial of Medicare Prescription Drug Coverage.

Submission methods: Submit by mail to Aspirus Health Plan Attn: Appeals and Grievances PO Box 51 Minneapolis, MN 55440-9972; by fax to 1-855-931-4857; via website aspirushealthplan.com/medicare/; expedited requests may be made by phone at 1-855-931-4858 (TTY: 1-855-931-4852).

Required information and documentation: Include enrollee name, DOB, address, phone, member ID; prescription drug details (name, strength/quantity/dose); whether drug was purchased pending appeal (receipt if purchased) with date and amount paid and pharmacy contact; reasons for appeal; supporting medical records and prescriber statement if available; and signature of the person requesting the appeal.

Policy Summary

PayerAspirus Arise

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribers may submit an appeal on behalf of the enrollee; a prescriber supporting statement enables expedited (72-hour) review when waiting 7 days could seriously harm the enrollee.

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.

Terms and Definitions

Representative

Who qualifiesEnrollee, the enrollee's prescriber, or another individual who is the enrollee's authorized representative (documentation such as CMS-1696 required).

How to appoint a representativeAttach documentation showing authority to represent the enrollee (completed Authorization of Representation Form CMS-1696 or written equivalent) if not already submitted; contact the plan or 1-800-Medicare for more information.

When a prescriber may actThe enrollee's prescriber may ask for an appeal on the enrollee's behalf without separate representative documentation noted in the form.

Contact for questionsContact Aspirus Health Plan for instructions on naming a representative.

Expedited appeal

DefinitionAn expedited (fast) decision is a review provided sooner than the standard timeframe because waiting could seriously harm the enrollee's life, health, or ability to regain maximum function.

Prescriber-supported timeframeIf the prescriber indicates waiting 7 days could seriously harm the enrollee, Aspirus will give a decision within 72 hours.

Plan discretionIf there is no prescriber statement, the plan will decide whether the case requires a fast decision and may still grant an expedited review if warranted.

LimitationAn expedited appeal cannot be requested for reimbursement of a drug already received (i.e., to be paid back).

OpenPayer

Request for Redetermination of Medicare Prescription Drug Denial

Redetermination Request Requirements

Prescriber-submitted Appeals and Expedited Requests

Terms and Definitions