Information for providers

PHARMACY – MEDICARE ADVANTAGE PLANS

Medicare Advantage Plans Formulary

A Formulary outlining the covered drugs and associated limitations, along with criteria used for prior authorization is available:

2022 Formulary
2021 Formulary

Pharmacy Benefit Prior Authorization Resources

Express Scripts, Inc. (ESI) is the pharmacy benefit manager for Aspirus Health Plan Medicare Advantage beneficiaries. All covered new and refill prescriptions should be processed through ESI.

ePA is the preferred method to submit Prior Authorization requests to Express Scripts for pharmacy benefit drugs. Providers may use ePA through ExpressPAth, Sure Scripts, CoverMyMeds or through the Electronic Health Record.

Express Scripts coverage review can be reached by phone at 1-877-558-7521 or by fax at 1-877-251-5896.

Request for Medicare Prescription Drug Coverage Determination (PDF)

Medical Injectable Drug Prior Authorization Resources

Care Continuum, a subsidiary of Express Scripts, reviews Medical Drug Prior Authorization requests for all Aspirus Health Plan Medicare Advantage plans.

Submit an authorization request using one of the following ways:

  • Online (ePA) via the ExpressPAth Portal at https://www.express-path.com. Providers can submit requests, check on the status of submitted requests, and submit an authorization renewal on the ExpressPAth Portal. The site also provides 24/7 access, potential for real-time approvals and email notifications once a decision is reached.
  • Fax a Prior Authorization Request Form (PDF) to Care Continuum at 1-866-540-8935.
  • Call Care Continuum at 1-866-540-8289.

To request an adjustment to an existing prior authorization:

  • The authorization must be active.
  • End date extensions can be completed due to scheduling issues or health reasons (ex: chemo delayed due to blood count) that may prevent the administration of the previously approved drug.
  • Required information for these requests:
    • Reason for extension.
    • Revised end date.
  • Adjustments are not approved for the reasons listed below. A new review/renewal is required.
    • Additional drug is requested.
    • The patient is due for a renewal.

Non-participating providers should send the Medical Injectable Drug Prior Authorization Request Form (PDF)

  • by fax to Aspirus Health Plan Clinical Services at 715-787-7319
  • or by mail to Aspirus Health Plan, Attn: Clinical Services at P.O. Box 51, Minneapolis, MN 55440-9972

Providers that received a claim denial due to no authorization in place will continue to work through the provider claims appeal process using the Provider Claim Reconsideration Request Form (PDF).

Resources

Medication Therapy Management Program Information
Prescription Drug Transition Policy (PDF)

Express Scripts Mail Order Pharmacy can be reached by phone at 1-866-544-7950 or by fax at 1-800-837-0959. e-Prescribing: Express Scripts Home Delivery Pharmacy

Pharmacy Network – Aspirus Health Plan Medicare members have access to a preferred pharmacy network, including Aspirus pharmacies. Costs for some drugs may be less at pharmacies in this preferred network. Find pharmacies using our online pharmacy directory.

Pharmacy & Therapeutics Committee Decisions

March 2022 Pharmacy & Therapeutics Committee Decisions (PDF)
January 2022 Pharmacy & Therapeutics Committee Decisions (PDF)
November 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
September 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
June 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
April 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
March 2021 Pharmacy & Therapeutics Committee Decisions (PDF)
January 2021 Pharmacy & Therapeutics Committee Decisions (PDF)