CurrentAspirus ArisePolicy N/A

Request for Medicare Drug Coverage Determination (Prior Authorization / Formulary Exception)

Form and instructions for beneficiaries, prescribers, or authorized representatives to request Medicare drug coverage determinations (prior authorization, formulary exceptions, tiering, quantity limits, expedited decisions) from Aspirus Arise. Affects plan enrollees, prescribers, and representatives seeking drug coverage decisions.

Policy Summary

PayerAspirus Arise

PolicyRequest for Medicare Drug Coverage Determination (Prior Authorization / Formulary Exception)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed form with prescriber supporting information including diagnosis (ICD-10), medication details, drug history with dates and outcomes, and clinical rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24form fields and checklist items (approx.)

24/7contact options (phone, mail, fax, online)

24-72hdecision timeframes

Coverage determination & review criteria

Formulary exception / prior authorization criteria

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Formulary exception / prior authorization

Completed form identifying the drug, dosage, quantity, and request type (e.g., formulary exception, tiering exception, quantity‑limit exception, prior authorization).
Prescriber provides diagnoses with corresponding ICD‑10 code(s).
Clinical justification
- Documentation of prior drugs tried for the condition with dates, doses, and results (including failure or intolerance).
- Documented contraindication to formulary or preferred alternatives with specific reason why alternatives are unsuitable.
- A clear clinical rationale for medical necessity (for example: patient is stable on current therapy and change would risk significant adverse clinical outcome; need for different dosage form or higher dosage with explanation).
If quantity limits are at issue, prescriber lists unit dose/total daily dose tried and provides rationale for exception.
Any additional supporting documents attached (e.g., medical records).
Prescriber must complete the Supporting Information pages (drug history, diagnoses with ICD‑10 codes, rationale) as indicated on the form.

Expedited review

Expedited (fast) review is available for requests where delay could seriously harm the enrollee.

Expedited review: Grant expedited review when the prescriber certifies that waiting the standard 72‑hour timeframe could seriously jeopardize the enrollee's life, health, or ability to regain maximum function; with a supporting prescriber statement the plan will issue a decision within 24 hours.Decision within 24 hours with prescriber support; otherwise plan assesses for expedited need (standard 72 hours)

If the prescriber does not support the expedited request, the plan will decide whether the case meets criteria for expedited review. Expedited review is not available for requests for reimbursement of a drug already received (retrospective reimbursement).

Diagnosis codes and decision timeframes

Diagnosis codesICD-10

ICD-10

Space provided to list ICD-10 diagnosis codes for conditions treated with the requested drug

Expedited review timeframe

Standard timeframeStandard review timeframe: decision within 72 hours unless expedited criteria met.

Expedited with prescriber supportIf the prescriber certifies that waiting 72 hours could seriously harm the enrollee, the plan will automatically issue a decision within 24 hours.

Expedited without prescriber supportIf no prescriber support is provided, the plan will assess the request and determine whether expedited (fast) review is warranted; standard 72‑hour process applies until determined otherwise.

What the prescriber / requester must provide

Documentation Required

Required documentation

Submit completed request form plus required supporting documentation. Include the completed prescriber sections (Diagnosis & Medical Information, Drug History, Rationale for Request), ICD-10 code(s), medication name/dose/route/frequency, dates of prior trials, and documentation of failure or intolerance. If someone other than the enrollee or prescriber is submitting, include a signed Authorization of Representation (e.g., CMS-1696) or equivalent.

Patient identifying information (name, DOB, address, phone, member ID).
Completed prescriber sections: Medication, Strength/route, Frequency, Date started, Expected length of therapy, Quantity per 30 days, Height/Weight, Drug allergies.
Diagnosis with corresponding ICD-10 code(s) for the condition(s) treated; if treating a symptom, provide the underlying diagnosis.
Drug name, dosage, quantity, and route for the requested therapy.
Authorization of Representation (CMS-1696) or equivalent if requester is not the enrollee.
Any additional supporting clinical records (labs, notes) demonstrating medical necessity.

Step Therapy

Step therapy / formulary exception requirements

Step therapy / formulary exception details required from prescriber. Document prior drugs tried, dates of trials, outcomes (therapeutic failure vs intolerance vs adverse reaction), maximum dose and duration used, or specific contraindications to preferred agents. Explain why alternatives are not appropriate and include clinical rationale (risk of significant adverse outcome, stability on current therapy, need for specific dosage form/strength).

List of drugs tried for the same condition with trial start/end dates.
Results of each previous drug trial: therapeutic failure (include max dose & length), intolerance, or adverse event (describe).
If requesting a tier/formulary exception, identify formulary/preferred drug(s) tried and outcomes.
If contraindication claimed, provide specific clinical reason why preferred drug(s) are contraindicated.
If requesting quantity-limit or prior authorization exception, specify unit dose/total daily dose tried when relevant.

Denial Risk

Missing prescriber support

Missing or incomplete prescriber support may delay or cause denial. Requests lacking required prescriber statements, ICD-10 codes, details of prior therapies, or Authorization of Representation when required may be returned for more information or denied.

Incomplete drug-history (missing dates, outcomes, or doses) risks denial.
Absence of ICD-10 diagnosis codes or insufficient clinical rationale may result in return for more information.
Missing Authorization of Representation when applicable will delay processing.

Policy background and purpose

This form documents the clinical justification needed to request exceptions and coverage determinations for Medicare drug benefits, including prior authorization, formulary or tiering exceptions, and quantity limit overrides. To evaluate a request the plan requires a completed form with prescriber-supplied supporting information: the diagnosis and relevant ICD-10 codes, detailed medication information (drug name, dose, route, start date, expected length), and a drug history listing prior therapies with dates and outcomes. For formulary exception or step-therapy bypass requests the prescriber must document prior drugs tried and the reason(s) they were unsuitable (failure, intolerance, contraindication) and provide a clinical rationale and any additional medical records necessary to support the request.

Key definitions

Expedited decision (definition)

DefinitionAn expedited decision is a faster review granted when waiting the standard 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function.

Prescriber-supported outcomeIf the prescriber indicates that waiting 72 hours could seriously harm the enrollee and provides a supporting statement, the plan will automatically give a decision within 24 hours.

Plan assessment if no prescriber statementIf the requester does not include the prescriber's supporting statement, the plan will decide whether the case requires a fast decision and proceed accordingly.

ExclusionExpedited decisions are not available for requests to reimburse a drug already received (retrospective reimbursement).

Step therapy documentation requirements

Required field	What to document
Drugs tried (name and dates)	List each prior drug tried for the condition, with start and stop dates
Dose and duration of prior trials	Record the maximum dose and length of therapy for each prior drug trial
Clinical outcome of each trial	Document therapeutic failure, intolerance, toxicity, or other adverse outcomes for each prior drug
Reasons alternatives are unsuitable	Explain why formulary or preferred alternatives are contraindicated, less effective, or likely to cause significant adverse clinical outcomes
Stability on current therapy (if applicable)	If patient is stable on the current drug, describe the risk of harm from changing therapy (e.g., prior hospitalizations, loss of control)
Need for different or higher dosage form	Specify prior dosage forms/doses tried, outcomes, and medical rationale for a different formulation or higher strength

Quantity limit exception process

Quantity limit exception — prescriber requirements

Documentation required for quantity‑limit exceptionsPrescriber must list the unit dose and/or total daily dose previously tried and provide the clinical rationale for requesting an exception to the plan's quantity limit.

Drug history detailsProvide drug(s) tried with dates, doses, outcomes (failure, intolerance, adverse event) and maximum dose and length of therapy when relevant.

Rationale elementsState why alternatives are contraindicated, not as effective, or likely to cause adverse clinical outcomes; include specific clinical explanation when applicable.