Washington Utilization Management and Exception Process — Prescription Drugs (WA fully insured plans)
Defines how utilization management (formularies, step therapy, quantity limits, substitutions, and exceptions) is applied for Washington state fully insured Aetna plans and how providers may request exceptions or prior authorization for prescription coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria for Exceptions and Utilization Management
Exception for Step Therapy/Substitution/Non-Formulary/Tier
The requested medication may be covered when ANY of the following are met and documentation is provided:
Provider must document intolerance or contraindication.
Document prior adverse reaction or lack of efficacy.
Provider must explain clinical rationale and potential harms or interactions.
Clinical explanation required; provider must document why the required medication will cause adverse effects or issues with the patient taking the medication.
Dosage/Quantity Limit Exception
The requested medication may be covered if:
Documentation may be required.
Off-label Use Exception
Consideration for FDA indications and off-label use:
Sufficient clinical information and evidence required to demonstrate the medication is useful for the condition despite lack of FDA approval for that indication.
None explicitly listed.
None explicitly listed.
Provider Actions, Submission and Documentation Requirements
Prior authorization and exception submission
If a prescription is rejected, providers must submit a prior authorization (PA) or exception request to Aetna for review. Contact the Aetna Pharmacy Precertification Unit for assistance and to initiate the PA/exception process.
- Non‑Specialty Precertification Unit: 1-800-294-5979
- Specialty Precertification Unit: 1-866-814-5506
- Fax (Non‑Specialty): 1-888-836-0730
- Fax (Specialty): 1-866-294-6155
- Mail: Aetna Pharmacy Management, 1300 East Campbell Road, Richardson, TX 75081
Step therapy and other UM exception criteria
An exception to step therapy, formulary, substitution, or dosage/quantity limits may be granted when the provider documents one or more of the following: intolerance or contraindication to the required medication; prior trial of the required drug with an adverse reaction or lack of effectiveness; clinical judgment that switching to the required drug would cause harm or adverse effects; or that the required drug is not in the patient’s best interest. For dosage/quantity limits, the provider must document that the requested clinically efficacious dosage is required for the patient’s treatment.
Required documentation for PA/exception requests
Providers must submit a completed prior authorization or exception form and relevant supporting documentation to substantiate the request. Supporting documentation may include medical records, clinical rationale, evidence of intolerance or contraindication, documentation of prior adverse reactions or treatment failure, medication history, and literature/compendia support for off‑label FDA indications when applicable.
- Complete and sign the applicable PA/exception form
- Include clinical notes, prior medication trials and outcomes, allergy/adverse reaction details, and any relevant test results
- Provide literature or compendia citations for off‑label use when claimed
Rejection triggers and common denial reasons
Prescriptions may be rejected if they do not meet utilization management criteria. Common rejection triggers include: requests for non‑formulary or non‑preferred medications without an approved exception, failure to satisfy step therapy requirements, exceeding dosage or quantity limits without justification, missing or incomplete prior authorization/exception forms or supporting documentation, and substitution rules or brand‑vs‑generic penalty issues without an approved exception (e.g., brand penalty or tier exception).
- Formulary / non‑preferred status without approved exception
- Unmet step therapy requirements
- Dosage or quantity exceeds limits without documented clinical justification
- Incomplete or missing PA/exception form or supporting records
- Brand‑vs‑generic penalty or tier exceptions not approved
Key Definitions
Background and Scope
This document explains the administrative utilization management and exception review process that applies to prescription drug requests for Washington fully insured Aetna plans. Applicable UM rules include formulary placement, step therapy, dosage/quantity limits, and substitutions. If a prescription is rejected, the provider may request an exception by completing and submitting the appropriate prior authorization form; providers should contact the Aetna Pharmacy Precertification Unit for Non‑Specialty at 1‑800‑294‑5979 or Specialty at 1‑866‑814‑5506, fax forms to Non‑Specialty 1‑888‑836‑0730 or Specialty 1‑866‑294‑6155, or mail to Aetna Pharmacy Management at 1300 East Campbell Road, Richardson, TX 75081. During review, Aetna will evaluate submitted documentation to determine whether the request meets criteria for an exception; medical necessity requirements may also apply.
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