Winter 2019 
Doctor's Note

In this issue, we help you prepare for the new year by outlining several changes that will go into effect on Jan. 1, 2020.
We include updates pertaining to our Prescription Drug Program, Formulary/Preferred Drug List, and step therapy protocols. Additionally, this issue contains information on how provider portal administrators can ensure your account is up to date, along with the most recent updates to our medical policies.
We appreciate the care you give your patients and our customers. If you have any questions, please contact me by email at or by phone at 608-977-8038.  


Jonah Fox, M.D., M.H.A. 
Medical Director 
Prescription Drug Program updates go into effect Jan. 1

Information regarding our Prescription Drug Program can be found on our website. Specifically, you can access:
  • Our Drug Program Policy, which includes how the formulary is developed and maintained, the prior authorization program, how to pursue an exception, and information on generic substitution and quantity limits
  • The Drug Prior Authorization List, which identifies the applicable medications as well as who to contact to initiate the process
  • Specialty drug approval policies (see our Drug Prior Authorization Program page)
  • Formulary/Preferred Drug List
Formulary/Preferred Drug List changes for Jan. 1, 2020*

Preferred Drug List Exclusions with Alternatives**
Drug names listed in CAPITALS are BRAND NAME DRUGS. Drug names listed in lowercase are generic drugs.
Drug Class
Excluded Medications
Preferred Alternatives
Antivirals (oral)
Sitavig ǂ
acyclovir oral or cream, famciclovir, valacyclovir
Anti-Migraine Therapy
Onzetra Xsail ǂ
sumatriptan nasal spray, Zomig Nasal Spray
Multiple sclerosis (oral)
Aubagio ǂ
Gilenya, Mayzent, Tecfidera
Transmucosal Fentanyl Analgesics
Abstral , fentanyl citrate buccal tablets, Fentora, Lazanda, Subsysǂ
fentanyl citrate lozenges
ACE Inhibitors
Blood Glucose Meters and Test Strips
Bayer (Breeze, Contour), National Medical (Advocate), Omnis Health (Embrace, Victory), Roche (Accu-Chek), Trividia (TRUEtest, TRUEtrack), UniStrip, All other meters and strips that are not Abbott or Lifescan brand
Abbott (Freestyle, Precision)
LifeScan (OneTouch)
Novolin, Relion Novolinǂ
Drug Class
Excluded Medications
Preferred Alternatives
Antiemetics (Oral)
Akynzeo Capsulesǂ
granisetron, ondansetron, aprepitant, Varubi Tablets
Emend Powder Packetsǂ
aprepitant, Varubi Tablets
Chelating Agents
Jadenuǂ, Jadenu Sprinkleǂ
Factor VIII Recombinant Products
Nuwiqǂ, Recombinate, Xynthia, Xynthia Solofuse
Advate, Adynovate, Afstyla, Eloctate, Jivi, Kogenate FS, Kovaltry, Novoeight
Granulocyte Colony Stimulating Factors
Granixǂ, Neupogen
Nivestym, Zarxio
Thrombocytopenia Agents
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Tivorbexǂ, Vivlodexǂ, Zorvolex
diclofenac sodium, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen, piroxicam
diclofenac potassium, diclofenac sodium
Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
diclofenac sodium topical, Flector Patch
Long-Acting Beta-Agonist Inhalers
Striverdi Respimatǂ
Serevent Diskus
Long-Acting Muscarinic Antagonist Inhalers
Spiriva Handihaler, Spiriva Respimat, Tudorza Pressairǂ
Incruse Ellipta
Immunosuppressant Agents
Metabolic Agents

ǂExcluded beginning Jan. 1, 2020
*May be subject to prior authorization requirements
**Arise has a pharmacy exception process. Exceptions must be approved in advance for coverage.
Step therapy updates go into effect Jan. 1

Wisconsin Act 12 creates Wisconsin Statute, Section 632.866 Step therapy protocols. The newly created statute requires insurers, pharmacy benefit managers, and utilization review organizations who use step therapy protocols in their prescription drug coverage to comply with several new requirements. Step therapy protocols must be established using specified clinical review criteria, there must be an exception process, and the process must allow exceptions under specified circumstances. Additionally, websites are required to provide a description and access to the process and criteria used to develop protocols and the exception process.
Exception Process
We may grant an exception to our step therapy protocol if the prescribing provider submits complete, clinically relevant written documentation supporting the request; and ONE of the following:
  • The prescription drug (Rx) required under the step therapy protocol is contraindicated, or (due to a documented adverse event with a previous use or a documented medical condition, including a comorbid condition) is likely to do any of the following:
    • Cause a serious adverse reaction in the patient
    • Decrease the ability to achieve or maintain reasonable functional ability in performing daily activities
    • Cause physical or psychiatric harm to the patient
  • The Rx required under the step therapy protocol is expected to be ineffective based on ALL of the following:
    • Sound clinical evidence or medical and scientific evidence
    • The known clinical characteristics of the patient
    • The known characteristics of the prescription drug regimen as described in peer-reviewed literature or the manufacturer's prescribing information for the Rx.
  • The patient has tried the Rx required under the step therapy protocol or another Rx in the same pharmacologic class, or with the same mechanism of action, under the policy or plan or a previous policy or plan; the patient was adherent to the prescription drug regimen for a time that allows for a positive treatment outcome; and the patient's use of the Rx was discontinued by the patient's provider due to lack of efficacy or effectiveness, diminished effect, or adverse event.
  • The patient is stable on an Rx selected by his/her health care provider for the medical condition under consideration while covered under the policy or plan or a previous policy or plan.
We are allowed to require a patient to try another drug in the same pharmacologic class or with the same mechanism of action if that therapy sequence is supported by the required clinical review criteria we developed.
The provision of pharmaceutical samples to a patient will not satisfy a criterion for an exception to a step therapy protocol.  
Turnaround Time
We will approve or deny a step therapy protocol exception request or appeal of a previously denied step therapy protocol exception request within three business days of receipt of the complete clinically relevant written documentation stated above. Upon approval of an exception to our step therapy protocol, we will process the Rx as indicated in the customer's health plan, certificate, or policy.
The text of the law may be accessed at .
For more information on step therapy protocols, contact our pharmacy department at 800-332-0899.
Medical Policy Updates and review

The Medical Policy Committee recently met and approved the medical policies due for annual review. 
Click here  to view the revisions to medical policies. 
Please be sure all doctors, other clinical staff, and office staff are aware of these changes before submitting requests for coverage. We ask you share these policy changes with providers who may be ordering or performing services and clinicians who may be referring patients for services.
The complete library of our medical policies can be found at  Arise Coverage Policy Bulletins  on our website; no password required.
A technology assessment process is applied to the development of new medical policies and review of existing policies. Policies are reviewed annually, or sooner when there is a significant change reported in the scientific evidence. Published scientific evidence, clinical updates, and professional organization guidelines are reviewed throughout the year, so you can forward a published article at any time.  
We value practitioner input regarding the content of our medical policies. If you have published scientific literature you would like to have considered or have questions or comments about policies, please forward them to our medical policy editor at or 800-333-5003, ext. 78993.
Policies that will be reviewed in the upcoming months include the following:
January 2020
  • Ankle Arthroplasty, Total (Total Ankle Replacement)
  • Meniscal Allograft Transplantation
  • Bone Growth Stimulators
  • Bone growth stimulators
  • Biofeedback Treatments and Devices
  • Neuropsychological Testing
  • Deep Brain Stimulation and Responsive Cortical Stimulation
Provider portal administrators: Is your account up to date?

As a provider portal administrator, you are responsible for safeguarding the security of your patients' accounts by regularly reviewing user access to ensure employees who have terminated or who should no longer have access to the portal are deactivated. In an effort to keep account access current, we will periodically send encrypted emails to the email address associated with the provider administrator's account. This email will contain a list of active users registered to the same tax ID. Upon receipt of the email, we ask that you review the list of users and notify us if all users are active or of any that should be deactivated.

You do not need to wait until you receive the email to deactivate a user's access. If you have a user whose access needs to be deactivated, you may send a secure message via the provider portal or call Web Support at 888-915-5477, option 2. When you call, please have the following information available:
  • User's first and last name
  • Email address the account was registered under and/or user ID
  • Two remittance dates and amounts
  • Tax Identification Number (TIN)
  • Office name
Arise Health Plan | P.O. Box 11625 | Green Bay, WI |

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