Pharmacy Clinical Policies | Resources | Prior Authorization List

PreferredOne updates its clinical policies and prior authorization (PA) list regularly and reserves the right to amend the prior authorization list and/or policies at any time. If material amendments are made to any policy or PA list, PreferredOne will disclose this information to contracted healthcare providers no less than 45 days prior to the implementation of any new or updated policy or PA list changes. PreferredOne reserves the right to amend non-material updates to the PA list or any policy at any time without disclosure. Click on the “Medical Policy and Pharmacy Policy Future Updates” link to the right for the latest updates.

Aspirus Health Plan updates its clinical policies and prior authorization (PA) list regularly and reserves the right to amend the prior authorization list and/or policies at any time. If material amendments are made to any policy or PA list, Aspirus Health Plan will disclose this information to contracted healthcare providers no less than 60 days prior to the implementation of any new or updated policy or PA list changes. Aspirus Health Plan reserves the right to amend non-material updates to the PA list or any policy at any time without disclosure.

Important note: Before using these policies, read Coverage Policy Usage Notice.

Before services are rendered, read Prior Authorization List & Policy Usage Notice, Site of Care Policy Information.

Before services are rendered, read Prior Authorization List & Policy Usage Notice.

PreferredOne has a pre-payment, post service claim edits (PSCE) program on specific medically administered medications. For more information, click here.

Aspirus Health Plan has a pre-payment, post service claim edits (PSCE) program on specific medically administered medications. For more information, click here.

Drugs and services excluded from coverage that are on the Pharmacy Investigative List are here.

The following medical drugs are excluded from coverage and are on the Cost Benefit List.

  • Cortrophin Gel (repository corticotropin)
  • H.P. Acthar Gel (repository corticotropin) J0800
  • Makena (hydroxyprogesterone caproate) J1726 (generic J1729 can be used without prior authorization)
  • Quzyttir (cetirizine hydrochloride injection) J1201
  • Susvimo (Ranibizumab, intravitreal implant) J2779

For Hyaluronic Acid Derivatives, Euflexxa, Synvisc, and Synvisc-One are covered without prior authorization when administered according to policy and are subject to post-service claim edits. All other hyaluronic acid derivatives are considered non-preferred and excluded.

For other preferred, non-preferred, and non-covered products, see a summary here.

Prior Authorization Drug List

* Indicates Site of Care Criteria Applies (PC/S009) Site of Care List.pdf
+ Indicates Post-Service Claim Edits Apply PSCE Drug List.pdf

+ Indicates Post-Service Claim Edits Apply PSCE Drug List.pdf