Aspirus Arise Coverage Criteria
Latest Aspirus Arise coverage criteria updates20
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01September 2025 P&T formulary decisions (partial) — Pharmacy & Specialty Drugs coverage criteriaSummarizes Pharmacy & Therapeutics Committee decisions on formulary status, new indications, generics, and dosage-form launches for multiple drugs that affect Aspirus Medicare formulary placement and prior authorization/step therapy rules.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-01Bone Mineral Density StudiesDefines covered methods and coverage criteria for bone mineral density testing (e.g., DXA, SEXA, QCT) for Aspirus Medicare Advantage products and explains frequency and medical necessity considerations.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-01SeptoplastyDefines coverage for septoplasty and repair of vestibular stenosis for Aspirus Medicare Advantage products, excluding cleft lip/palate management and cosmetic rhinoplasty. Applies to outpatient surgery benefit.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Reconstructive and Cosmetic Health ServicesDefines medical necessity criteria and coverage stance for reconstructive versus cosmetic surgical and nonsurgical services for Aspirus Health Plan members; applies to providers requesting coverage determinations and prior authorization for reconstructive services.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-15Hematology - Adzynma Utilization Management Medical PolicyDefines prior authorization, coverage criteria, dosing, and documentation requirements for Adzynma for treatment of congenital thrombotic thrombocytopenic purpura for Aspirus Medicare Plans.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-11-15Adstiladrin (nadofaragene firadenovec) for NMIBC — Oncology (Intravesical) - Adstiladrin UM Medical PolicyCovers prior authorization, coverage criteria, dosing, and approval durations for Adstiladrin intravesical therapy in adults with high-risk BCG-unresponsive non‑muscle invasive bladder cancer; applies to Aspirus Medicare plans and requires specialist prescribing or consultation.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-11-15Adstiladrin (nadofaragene firadenovec) intravesical therapy — Coverage CriteriaPrior-authorization and coverage criteria for Adstiladrin for adults with high-risk BCG-unresponsive non‑muscle invasive bladder cancer (NMIBC) with CIS with or without papillary tumors, for Aspirus Arise plans.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-07-01Abecma (idecabtagene vicleucel) CAR‑T therapy coverageDefines prior authorization, coverage criteria, dosing, and exclusions for Abecma (idecabtagene vicleucel) for Aspirus Medicare Plans for treatment of relapsed/refractory multiple myeloma.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Adcetris (brentuximab) Utilization Management Medical PolicyDefines authorization, dosing, and coverage criteria for Adcetris (brentuximab) for Aspirus Medicare plans, including FDA‑approved indications and recommended documentation/authorization processes for oncology providers.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Aldurazyme (laronidase) — Enzyme Replacement Therapy for MPS IThis policy governs prior authorization and medical necessity criteria for coverage of Aldurazyme (laronidase) for treatment of Mucopolysaccharidosis type I (MPS I) for Aspirus Medicare plans and applies to providers prescribing or requesting authorization.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Aliqopa (copanlisib IV) Utilization Management Medical PolicyDefines prior authorization, coverage criteria, dosing, and restrictions for Aliqopa (copanlisib IV) for Aspirus Medicare Plans; applies to providers prescribing or requesting coverage for Aliqopa.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Enzyme Replacement Therapy - Aldurazyme (laronidase) Utilization Management Medical PolicyThis policy governs prior authorization, coverage criteria, dosing, and prescribing specialist requirements for Aldurazyme (laronidase) for treatment of Mucopolysaccharidosis type I (MPS I) across Aspirus Medicare Plans and related Aspirus Arise lines.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Inflammatory Conditions - Tocilizumab Intravenous Products Utilization ManagementPrior authorization and coverage criteria for intravenous tocilizumab products (Actemra, Avtozma, Tofidence) for Aspirus Medicare Plans, including indication- and dosing-based authorization rules and preferred product step therapy.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Inflammatory Conditions - Tocilizumab Intravenous Products Utilization Management Medical PolicyPrior authorization and coverage criteria for intravenous tocilizumab products (Actemra, Avtozma, Tofidence) for Aspirus Medicare Plans; defines indications, dosing, step therapy, and authorization durations for medical benefit coverage.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Inflammatory Conditions Tocilizumab Intravenous Products Utilization Management Medical PolicyThis policy governs prior authorization, coverage criteria, dosing, and specialty prescriber requirements for intravenous tocilizumab products (Actemra, Tofidence and listed biosimilars) for Aspirus Medicare plans.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Repository Corticotropin (Acthar Gel) — Utilization ManagementDefines prior authorization, coverage criteria, dosing, and non-coverage conditions for Acthar Gel for members of Aspirus Medicare Plans, and directs prescribing by or in consultation with specialists.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Sickle Cell Disease - Adakveo (crizanlizumab) Utilization Management Medical PolicyDefines prior authorization and medical necessity criteria for coverage of Adakveo (crizanlizumab-tmca) to reduce vaso-occlusive crises in patients with sickle cell disease for Aspirus Medicare Plans.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyAuthorization and Notification RequirementsLists services that require prior authorization or notification for Aspirus Health Plan providers, with procedural codes, requirements, and referenced medical necessity criteria. Applies to providers submitting requests for inpatient, outpatient, DME, procedures, diagnostics, and related services.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyCoverage criteria for non-preferred continuous glucose monitors (CGMs) and glucose testing suppliesCovers authorization and criteria for non-preferred continuous glucose monitors (CGMs) and non-preferred glucose testing supplies for members with diabetes; applies to Aspirus Arise members and providers ordering these products.All Aspirus Arise updates
- Coverage CriteriaClinical/Medical PolicyHome health and home infusion pre-certification/authorization form coverage criteriaThis document is a pre-certification and authorization request form used by CARECONTINUUM for home health, home infusion, MDO, or AIC services and applies to providers requesting coverage through Aspirus Arise. It collects patient, clinic, prescriber, and requested drug/service information to support utilization review.All Aspirus Arise updates
1–20 of 20
1 / 1
Tool Description
Search Aspirus Arise coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
Coverage Criteria by Payer
Go deeper
Explore OpenPayer Data
Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Prior Authorization LookupSearch payer prior authorization policies by drug, procedure, or policy name.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.