CurrentAspirus ArisePolicy N/A

Medicare drug coverage determination / prior authorization form

Form and instructions for requesting a Medicare drug coverage determination, prior authorization, or formulary exception from Aspirus Arise; intended for plan enrollees, prescribers, or authorized representatives seeking coverage decisions for prescription drugs.

Policy Summary

PayerAspirus Arise

PolicyMedicare drug coverage determination / prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit a completed form with diagnosis, ICD-10 codes, drug history, rationale, dosing, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursexpedited decision timeframe with prescriber support

72 hoursstandard decision timeframe

1-855-668-8552fax

PO Box 1039mail

Coverage determination criteria

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Prescriber statement and supporting info: Prescriber must complete supporting information pages documenting diagnosis, ICD-10 code(s), medication details (strength, route, frequency, start date, expected length of therapy, quantity per 30 days), and sign the form.

Drug history and prior trials: Document drugs tried for the condition(s), dates of trials, results (failure vs intolerance), and the enrollee's current drug regimen; include unit dose/total daily dose, doses and durations where relevant.

Type of exception requested: One of: formulary exception, tiering exception, quantity limit exception, prior authorization, or step therapy exception as indicated on the form.

Rationale for exception: Provide specific clinical rationale why alternatives were ineffective or caused adverse outcomes, why alternatives are contraindicated or less effective, why the patient would suffer harm if required to satisfy prior authorization/step therapy, or why the patient is stable on current therapy such that changing medications would risk significant adverse clinical outcome. Include details of prior trials (drugs, results, maximum dose and length of therapy) when not already in drug history.

Safety and high-risk considerations: If applicable, provide relevant safety information such as contraindications, anticipated adverse clinical outcomes, and medical need for different dosage form or higher dosage with explanation why lower-frequency/higher-strength alternatives are not appropriate.

Prescriber / Provider requirements and actions

Prior Authorization

Prior Authorization / Formulary Exception Required

Prior authorization or a formulary exception is required for certain drug requests. The prescriber must complete and submit the Supporting Information for an Exception Request or Prior Authorization (pages 3–4) when requesting prior authorization or a formulary exception. Failure to submit a completed prescriber form and required documentation may delay processing or result in denial.

Prescriber-completed supporting information required: diagnosis(es) with corresponding ICD-10 code(s); medication name, strength, route, frequency, date started, expected length of therapy, quantity per 30 days, height/weight, and drug allergies.
Include completed ‘Supporting Information for an Exception Request or Prior Authorization’ form (pages 3–4) signed by the prescriber. Mark if requesting expedited (72-hour) review and certify clinical urgency if applicable.
If the request is for a formulary exception, indicate which type: non-formulary drug, brand when generic/biosimilar available, removal-from-formulary continuation, step therapy exception, quantity limit exception, prior authorization rule exception, or tiering exception.

Denial Risk

Insufficient Documentation May Trigger Denial

Insufficient or missing documentation required from the prescriber may result in a denial or a decision based on incomplete information. Provide complete clinical rationale and supporting records to avoid denial or the need for additional information requests.

Missing prescriber signature, absent ICD-10 codes, or incomplete drug history are common reasons for denial.
If requested documentation (e.g., prior records, trial dates, reasons for failure) is not provided, the plan may deny the request or deem it not medically necessary.

Documentation Required

Required Supporting Documentation

Submit complete supporting documentation with the request. Use the designated form fields and attach any relevant clinical notes, test results, or prior authorization history to substantiate the request.

Required supporting documentation: completed prescriber form with prescriber name, contact information, and signature; diagnosis(es) with ICD-10 code(s); detailed drug history (see DRUG HISTORY section); current medication regimen; quantity and dosing information.
Attach clinical notes, lab results, hospitalization records, or other documentation that support medical necessity and the rationale provided.

Step Therapy

Step Therapy Exception Documentation

For step therapy exception requests, document prior therapies tried and provide clear reasons for failure or contraindication to each required step. State dates, doses, outcomes, and whether the failure was therapeutic failure or intolerance.

List drugs tried for the condition, dates of trials, doses and maximum tolerated doses, and outcomes (therapeutic failure vs intolerance).
If an alternative is contraindicated, provide a specific clinical explanation why preferred/step drugs are inappropriate or would cause significant adverse clinical outcome.
If patient is stable on current therapy, include details demonstrating clinical stability and risk of harm if therapy is changed.

Key definitions

Expedited decision (inv-08)

DefinitionExpedited decision = a faster coverage determination given when the prescriber indicates that waiting the standard 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function.

Decision timeframe when prescriber supports expedited requestDecision provided within 24 hours if prescriber certifies that waiting 72 hours could seriously harm the enrollee.

Standard timeframe for non‑expedited requestsStandard decision timeframe is 72 hours unless expedited criteria are met.

Prescriber supporting statementIf you have a supporting statement from your prescriber, attach it to the request to support the expedited decision.

Plan review without prescriber supportIf prescriber support is not provided, the plan will determine whether the case qualifies for a fast decision.

LimitationExpedited review is not available for requests for reimbursement of a drug already received (no retroactive expedited decision).

Authorized representative (inv-09)

DefinitionAuthorized representative = a person acting on behalf of the plan enrollee who submits the request when they are not the enrollee or prescriber.

Documentation requiredSubmit documentation showing authority to represent the enrollee (a completed Authorization of Representation Form CMS‑1696 or equivalent).

When to provideProvide the authorization form or equivalent whenever the requester is not the enrollee or the prescriber signing the request.

Contact for appointing a representativeFor more information on appointing a representative, contact the plan or call 1‑800‑MEDICARE (1‑800‑633‑4227); TTY 1‑877‑486‑2048.

Requestor information to includeInclude requestor name, relationship to enrollee, address, phone, and indicate submission of the authorization document on the form.

Background and purpose

This form is used to request Medicare drug coverage determinations including prior authorization, formulary or tiering exceptions, quantity‑limit overrides, and expedited (fast) decisions. It must be completed by the prescriber (or an authorized representative with documentation of authority) and include diagnosis with ICD‑10 code(s), medication details, history of prior therapies (dates, doses, outcomes), clinical rationale for the request, and a prescriber signature. For expedited requests, attach the prescriber’s supporting statement certifying why the standard 72‑hour timeframe would cause serious harm; with that support the plan will decide within 24 hours.