Aspirus Arise Prior Auth Coverage Update

Tretinoin cream (0.025%,0.05%,0.1%) — Initial coverage

Covered when ALL of the following are met

Tretinoin cream coverage: Drug is tretinoin cream in concentrations 0.025%, 0.05%, or 0.1%

PA indicator: All FDA-Approved Indications

Indication: Use is for an FDA-approved indication

PA Indication Indicator: 1 - All FDA-Approved Indications

Duration: Approved for duration of 1 year1 year

Coverage duration as stated

Actimmune — Initial coverage

Covered when ALL of the following are met

Actimmune coverage: Drug is Actimmune

Indication: Use is for an FDA-approved indication

PA Indication Indicator: 1 - All FDA-Approved Indications

Duration: Approved for duration of 1 year1 year

Coverage duration as stated

Initial and continuation therapy for atopic dermatitis

Covered when ALL of the following are met for atopic dermatitis:

Atopic dermatitis coverage criteria: Request is for Adbry for an FDA‑approved indication; for initial requests, member had an ineffective or not tolerated trial of a topical calcineurin inhibitor; member has moderate to severe atopic dermatitis with at least two of: intractable pruritus; cracking and oozing/bleeding; impaired activities of daily living; prescribed by or in consultation with an allergist, immunologist, or dermatologist; will not be used in combination with another targeted immunomodulator for the same indication; coverage duration limited to 1 year.

Continuation requires documented benefit; prerequisite therapy required for initial requests

ALYQ / Tadalafil (PAH) - Initial Coverage

ALYQ and Tadalafil (PAH) - covered when ALL of the following are met

ALYQ/Tadalafil Coverage: Diagnosis confirmed by right heart catheterization and indication is an FDA‑approved indication for the medication

Coverage duration approved for 1 year

Adempas - Initial Coverage

Adempas - covered when ALL of the following are met

Adempas Coverage: Diagnosis confirmed by right heart catheterization; indication is FDA‑approved; for pulmonary arterial hypertension, documented trial and ineffective or not tolerated trial of one endothelin receptor antagonist (ambrisentan, bosentan, or macitentan) and one phosphodiesterase-5 inhibitor (sildenafil or tadalafil)

Coverage duration approved for 1 year; for persistent/recurrent CTEPH (WHO Group 4) trial of other agents not required

Administrative coverage attributes

Covered when meeting listed administrative attributes

Administrative coverage attributes: Drug is one of the listed medications and indication is an FDA‑approved indication (PA indicator = 1) and coverage duration is approved for 1 year

Prerequisite therapy required for everolimus per document; Aimovig shows prerequisite therapy as N/A

Initial and Continuation Coverage Criteria

Covered with criteria for migraine prevention and other FDA-approved indications when the following are met:

Initial authorization for migraine prevention: Member has 4 or more migraine days per month for the previous 3 months or longer.>=4 migraine days/month for 3 months

Applies to initial requests only

Continuation authorization for migraine prevention: Member has benefited with use of this medication.clinical benefit documented

Applies to continuation requests only

Indication coverage: Indications covered include all FDA‑approved indications for AKEEGA.FDA-approved indication

Alecensa — Initial coverage

Covered when ALL of the following are met

Alecensa coverage: Drug is Alecensa and the request is for an FDA‑approved indication

Approval duration: 1 year

Prolastin‑C — Initial coverage

Covered when ALL of the following are met

Prolastin‑C diagnostic and attestation requirements: Diagnosis of congenital alpha1‑antitrypsin deficiency confirmed by (A) circulating baseline alpha1‑antitrypsin level <11 micromol/L or <50 mg/dL by nephelometry AND (B) high‑risk alpha1‑antitrypsin genotype (SS, SZ, ZZ, or null/null); and prescriber attests that member does not have IgA deficiency with known anti‑IgA antibody.

Approval duration: 1 year

Initial coverage criteria

Covered when ALL of the following are met

Diagnostic confirmation: Diagnosis of congenital alpha1‑antitrypsin deficiency is confirmed by: (A) circulating baseline alpha1‑antitrypsin level < 11 micromol/L or < 50 mg/dL by nephelometry AND (B) high‑risk genotype (SS, SZ, ZZ, or null/null)see threshold

Prescriber must attest absence of IgA deficiency with anti‑IgA antibody

Prescriber requirement: Prescribed by, or in consultation with, a pulmonologist when applicable

PA indication: Prior authorization applies to ALUNBRIG and ALYFTREK for all FDA‑approved indications

Approval duration: Coverage approved for 1 year

Alyftrek - Initial Coverage

Alyftrek is covered when ALL of the following are met

Alyftrek coverage: Indication must be an FDA‑approved indication; approved duration is 1 year.

No additional restrictions, exclusions, age, prescriber, or required medical information listed in this segment.

Arcalyst - Initial Coverage

Arcalyst is covered when ALL of the following are met

Arcalyst coverage: Indication must be an FDA‑approved indication; approved duration is 1 year.

No additional restrictions, exclusions, age, prescriber, or required medical information listed in this segment.

Initial Authorization

Covered when ALL of the following are met

Coverage conditions: (1) Drug is ARIKAYCE or AUGTYRO; (2) Indication is an FDA-approved indication; (3) Prescribed by, or in consultation with, an infectious disease specialist or pulmonologist; (4) Coverage duration limited to 1 year.

Initial therapy — Tardive Dyskinesia

Covered when ALL of the following are met for initial requests for tardive dyskinesia:

Initial TD coverage: One of the following: (i) Member has failed to respond to a change in current antidopaminergic therapy; OR (ii) Member is unable to switch current antidopaminergic therapy; OR (iii) Member has symptoms of tardive dyskinesia and is not using antidopaminergic therapy; AND member has a functional disability due to tardive dyskinesia.

Initial therapy — Chorea of Huntington disease

Covered when the following is met for initial requests for chorea associated with Huntington's disease:

Initial chorea coverage: Trial of other agents not required.

Continuation therapy

Covered when ALL of the following are met for continuation requests:

Continuation coverage: Member has benefited with use of this medication.

AVMAPKI FAKZYNJA - Initial Coverage

Covered when following general conditions are met:

AVMAPKI FAKZYNJA coverage: PA indicates coverage for all FDA-approved indications

Approved duration 1 year

AYVAKIT - Initial Coverage

Covered when following general conditions are met:

AYVAKIT coverage: PA indicates coverage for all FDA-approved indications

Approved duration 1 year

Initial coverage

Covered when ALL of the following are met

FDA indication: Indication must be FDA-approved for the drug (PA Indication Indicator = 1)

Duration: Coverage approved for 1 year1 year

Initial and Continuation Coverage Criteria

Covered when ALL of the following are met for each respective medication:

BENLYSTA - Initial SLE: Diagnosis of active systemic lupus erythematosus confirmed by one of: anti-dsDNA >30 IU/mL OR low complement (C3/C4) OR positive anti-Smith antibodies; two of the following were ineffective or not tolerated: hydroxychloroquine, methotrexate, azathioprine, mycophenolate, or a corticosteroid; prescriber is a rheumatology specialist, nephrologist, or dermatologist; prescriber attests member does not have severe active CNS lupus; member is not taking other biologics; approved for duration of 1 year.

For active lupus nephritis: will not be used in combination with voclosporin (Lupkynis).

BENLYSTA - Continuation: Prescriber attests member has benefited with use of this medication; prescriber specialty restriction as above; approved for duration of 1 year.

BESREMI: Trial of at least one anti-epileptic medication was ineffective or not tolerated; prescribed by, or in consultation with, a neurologist; approved for duration of 1 year.

Besremi (ropeginterferon alfa-2b) — polycythemia vera

Covered when ONE of the following is met for polycythemia vera:

High-risk pathway: Both of the following: (i) High risk disease defined by one of: age >= 60 years OR history of thrombosis; and (ii) Trial of hydroxyurea was ineffective, contraindicated, or not tolerated.

Applies to Besremi

Low-risk pathway: Both of the following: (i) Low risk defined by both: age < 60 years AND no history of thrombosis.

Applies to Besremi

Bosulif (bosutinib)

Bosulif is listed under Part B with PA required for FDA‑approved indications and prerequisite therapy indicated.

General Bosulif requirements: Prior authorization required for FDA‑approved indications; prerequisite therapy required (details not specified in this segment); approved duration is 1 year.

Covered with criteria

Covered when the following apply for each medication listed:

BRAFTOVI coverage: Patient has a condition for which BRAFTOVI is indicated under FDA-approved labeling and prior authorization is requested; approval duration is 1 year.

PA indicator 1 = All FDA-Approved Indications

BRUKINSA coverage: Patient has a condition for which BRUKINSA is indicated under FDA-approved labeling and prior authorization is requested; approval duration is 1 year.

PA indicator 1 = All FDA-Approved Indications

N/A

For atopic dermatitis (all requests): Will not be used in combination with another targeted immunomodulator product for the prescribed indication.

No off-label uses, exclusions, or other criteria are specified in these parts of the document; entries are listed as N/A where applicable.

No off-label uses are listed in this segment; the document indicates N/A for off-label uses.

No off-label uses, exclusion criteria, or other special criteria are specified in this excerpt; applicable fields are recorded as N/A.

No off‑label uses, exclusion criteria, or other exclusions are specified in this segment; the document lists these items as N/A.

No explicit exclusion criteria are listed in this section; the policy records N/A where exclusions would be noted.

No off‑label uses are specified in this segment; off‑label fields are marked N/A.

No explicit exclusion criteria are listed in this section; entries are recorded as N/A where applicable.

No exclusions are listed in this portion of the document; the designation is N/A.

No off-label uses, exclusion criteria, or other special criteria are specified in this segment; relevant fields show N/A.

No off-label uses or exclusion criteria are specified in this section; entries are recorded as N/A.

For systemic lupus erythematosus: will not be given in combination with other biologics. For active lupus nephritis (all requests): will not be used in combination with voclosporin (Lupkynis).

No off-label uses, exclusion criteria, age restrictions, prescriber restrictions, or other criteria are specified in this section; applicable fields are listed as N/A.

No off-label uses or exclusion criteria are provided in this segment; explicit exclusions are listed as N/A.

N/A

Provider Actions — Prior Authorization, Documentation & Denial Risks

Prior Authorization

Prior Authorization Required for AKEEGA

Provider must obtain prior authorization from Aspirus Health Plan before dispensing AKEEGA; failure to obtain PA may result in non‑coverage.

PA applies to AKEEGA for all FDA‑approved indications.

Prior Authorization

Alyftrek Prior Authorization

A prior authorization is required for Alyftrek; coverage is limited to all FDA‑approved indications.

Prior Authorization

Arcalyst Prior Authorization

A prior authorization is required for Arcalyst; authorization applies to all FDA‑approved indications.

Prior Authorization

AVMAPKI FAKZYNJA Prior Authorization

AVMAPKI FAKZYNJA co‑pack requires prior authorization; authorization indicator covers all FDA‑approved indications.

Prior Authorization

BENLYSTA Authorization & Indication Coverage

BENLYSTA is subject to prior authorization and, per the PA indication indicator, is covered for all FDA‑approved indications when criteria are met.

Initial SLE requests require failure or intolerance of two baseline agents (e.g., hydroxychloroquine, methotrexate, azathioprine, mycophenolate, or a corticosteroid).
Prescriber must attest member does not have severe active CNS lupus and is not taking other biologics.

Denial Risk

Indication Restriction / Mismatch Risk

Requests for drugs listed with PA Indication Indicator = '1 - All FDA‑Approved Indications' will be evaluated only for FDA‑approved uses; requests for non‑FDA indications may be denied.

Documentation Required

Migraine Frequency Requirement

For migraine prevention medications (e.g., Aimovig), initial authorization requires documentation that the member experienced 4 or more migraine days per month for the previous 3 months; continuation requests require evidence of benefit.

Initial: ≥4 migraine days/month for prior 3 months.
Continuation: documentation of clinical benefit with therapy.

Documentation Required

Documentation Triggers for Tardive Dyskinesia

For tardive dyskinesia initial requests (e.g., Austedo), documentation must show either failure of a change in current antidopaminergic therapy, inability to switch, or TD symptoms without antidopaminergic therapy, and that the member has a functional disability due to TD. Continuation requests require objective benefit.

Initial TD: one of i) failed to respond to change in antidopaminergic therapy, ii) unable to switch, or iii) TD symptoms while not using antidopaminergic therapy; AND functional disability present.
Continuation: documentation of benefit.

Documentation Required

Polycythemia Vera Documentation Requirement for BESREMI

For Besremi use in polycythemia vera, required documentation depends on risk: either high‑risk disease with trial of hydroxyurea ineffective/contraindicated/not tolerated, or low‑risk disease (age <60 and no thrombosis).

High risk: age ≥60 or history of thrombosis AND trial of hydroxyurea ineffective/contraindicated/not tolerated.
Low risk: age <60 AND no history of thrombosis.

Documentation Required

Required Medical Information for Prior Authorization Requests

Providers must submit required medical information with PA requests. Required elements vary by drug and indication and include diagnostic confirmation, prior therapy trials, and attestation statements as specified in each medication's criteria.

Examples: diagnosis confirmed by right heart catheterization for PAH agents; documentation of prior topical calcineurin inhibitor trial for atopic dermatitis initial requests; prescriber attestation for Prolastin‑C regarding IgA status.
Provide all requested prior therapy details and objective evidence of benefit for continuation requests.

Documentation Required

Required Medical Information for Prolastin‑C

For Prolastin‑C, authorization requires both: 1) circulating baseline alpha1‑antitrypsin level below protective threshold (<11 micromol/L or <50 mg/dL by nephelometry) AND a high‑risk genotype (SS, SZ, ZZ, or null/null); and 2) prescriber attestation that the member does not have IgA deficiency with known anti‑IgA antibody.

Step Therapy

Prerequisite Therapy and Continuation Requirements

Prerequisite therapy requirements and continuation rules are specified per drug: some agents require documented prior trials of specific drug classes before approval; continuation typically requires evidence of clinical benefit.

Examples: Adempas for PAH requires prior trial of an endothelin receptor antagonist AND a phosphodiesterase‑5 inhibitor.
Everolimus and many oncology/rare disease agents list prerequisite therapy = YES where noted.

Step	Requirement
1
No prerequisite (step) therapies required (PREREQUISITE THERAPY REQUIRED = N/A).

Step	Requirement
1
Initial requests for Adbry require a prior trial of a topical calcineurin inhibitor that was ineffective or not tolerated (required medical information for atopic dermatitis initial requests).

Step	Requirement
1
For Adempas in pulmonary arterial hypertension: documented trial and ineffective/intolerant failure of one endothelin receptor antagonist (ambrisentan, bosentan, or macitentan) AND one phosphodiesterase‑5 inhibitor (sildenafil or tadalafil). Note: PREREQUISITE THERAPY REQUIRED is listed as YES for some agents and N/A for others in the document.

Step	Requirement
1
Prerequisite therapy is required prior to approval (PREREQUISITE THERAPY REQUIRED = YES for everolimus).

Step	Requirement
0
No prerequisite (step) therapy required for the agents listed in this segment (PREREQUISITE THERAPY REQUIRED = N/A).

Step	Requirement
1
For initial requests for tardive dyskinesia: one of the following must be met — (i) failed to respond to a change in current antidopaminergic therapy; (ii) unable to switch current antidopaminergic therapy; or (iii) has symptoms of TD and is not using antidopaminergic therapy — and member has a functional disability due to TD.

Step	Requirement
1
Prerequisite therapy required prior to approval: e.g., BENLYSTA initial SLE requests require failure or intolerance of two listed baseline agents; BESREMI requires trial of at least one anti‑epileptic medication (trial ineffective or not tolerated).

Step	Requirement
1
Prerequisite therapy required before BOSULIF may be approved (PREREQUISITE THERAPY REQUIRED = YES); specific prior therapy details are not provided in this excerpt.

Definitions and Clinical Thresholds

inv-120: Moderate to severe atopic dermatitis

DefinitionPresence of at least two of: intractable pruritus (itching); cracking and oozing/bleeding of skin; impaired activities of daily living

ContextUsed to define moderate to severe atopic dermatitis for initial Adbry requests

ImplicationMust be documented in medical record for PA decisions

inv-121: PA Indication Indicator

PA Indication Indicator — meaningIndicates coverage applies to all FDA‑approved indications for the listed medication

Numeric codeDisplayed in policy as '1 - All FDA-Approved Indications'

Applies toMultiple listed drugs in this document (e.g., Alecensa, Arcalyst, others)

inv-122: PA Indication Indicator

Policy impactRequests for non‑FDA indications are not supported under this indicator

Examples in documentUsed for multiple products including AKEEGA, ALYQ, and others

inv-123: Migraine day

Migraine day definition (implicit)A day with migraine symptoms counted toward the requirement of >=4 migraine days/month

Use in eligibilityDetermines eligibility for initial prevention therapy under this policy

Documentation periodMeasured over the previous 3 months or longer as documented in medical records

inv-124: Protective alpha1‑antitrypsin threshold

Protective alpha1‑antitrypsin threshold (definition)Circulating baseline alpha1‑antitrypsin level below 11 micromol/L or < 50 mg/dL by nephelometry

Measurement methodSpecified as measured by nephelometry in required documentation

Role in PAOne of two required diagnostics to confirm congenital AAT deficiency for Prolastin‑C coverage

inv-125: High‑risk alpha1‑antitrypsin genotypes

High‑risk genotypes listedSS, SZ, ZZ, or null/null

RelevanceGenotypes associated with increased risk for clinically significant alpha1‑antitrypsin deficiency

Documentation requirementRequired alongside low AAT level to confirm diagnosis for coverage

inv-126: Protective threshold

Protective threshold restatedCirculating baseline AAT < 11 micromol/L or < 50 mg/dL by nephelometry

Clinical useUsed to confirm congenital AAT deficiency for Prolastin‑C prior authorization

Pairing requirementMust be documented along with a high‑risk genotype (SS, SZ, ZZ, or null/null)

inv-127: High‑risk genotype

High‑risk genotype — conciseSS, SZ, ZZ, or null/null

AssociationLinked to congenital alpha1‑antitrypsin deficiency in policy diagnostic criteria

DocumentationRequired for Prolastin‑C authorization along with AAT level and prescriber attestation

inv-128: PA indication indicator 1

Policy consequenceRequests for non‑FDA uses may be denied under this indicator

Applied to multiple productsIndicator appears across several drug entries in the policy

inv-129: functional disability

Functional disability definitionFunctional disability due to tardive dyskinesia

Use in authorizationRequired to support initial TD treatment requests per policy

DocumentationMedical records must show functional impairment from TD for approval

inv-130: PA Indication Indicator

PA Indication Indicator — general meaningPA Indication Indicator '1 - All FDA-Approved Indications' means the PA covers FDA-approved uses for the product

Denial riskRequests outside FDA‑approved indications may not be supported

Common usageUsed consistently across many drug entries in this policy

inv-131: Active systemic lupus erythematosus confirmation

Active SLE confirmation testsAnti-double stranded DNA >30 IU/mL, low complement (C3/C4), or positive anti-Smith antibodies

Use in policyRequired laboratory evidence to confirm active systemic lupus erythematosus for BENLYSTA initial requests

Documentation pairingAlso requires documentation of prior therapies and prescriber attestations per policy

inv-132: Continuation benefit

Continuation benefit requirementMember must have benefited with use of BENLYSTA for continuation requests

DocumentationPrescriber must attest to clinical benefit in continuation requests

DurationContinuation approvals are granted for up to 1 year per policy

inv-133: PA Indication Indicator

PA Indication Indicator — PA scopeIndicates the drug is subject to prior authorization for all FDA‑approved indications

EffectLimits coverage consideration to FDA‑labeled uses

Appears onMultiple product entries across the document (PA indicator = 1)

inv-134: BRAFTOVI

Medication nameBRAFTOVI

ContextListed as a medication covered under PA with indicator = 1

Coverage noteApproval duration when authorized is 1 year

inv-135: BRUKINSA

Medication nameBRUKINSA

ContextListed as a medication covered under PA with indicator = 1

Coverage noteApproval duration when authorized is 1 year

AUSTEDO, AUSTEDO XR, AUSTEDO XR PATIENT TITRATION 12 & 18 & 24 & 30 MG TBER THPK	Medication names as listed in policy
AVMAPKI FAKZYNJA CO-PACK	Medication co-pack listed

OpenPayer

Prior authorization criteria — Essential Rx (PPO) medications

Coverage Criteria — Drug-specific Initial and Continuation Rules

Provider Actions — Prior Authorization, Documentation & Denial Risks

Coding — Listed Drugs and Key Clinical Thresholds

Initial Therapy Criteria by Medication

Continuation / Renewal Criteria and Duration

Step Therapy / Prerequisite Trials

Definitions and Clinical Thresholds

Background — Scope and Policy Context