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Washington Utilization Management and Exception Process — Prescription Drugs
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Governs prior authorization, step therapy, substitution, non-formulary and tier exception processes for Washington State fully insured Aetna members and informs providers how to request exceptions and authorizations.
No material clinical or coverage changes in this revision.
Coverage Criteria for Exceptions and Prior Authorization
Step Therapy/Substitution/Non-Formulary/Tier Exception
Requested medication may be covered when ANY of the following documented conditions are met:
Provider must document intolerance or contraindication
Document prior trial and adverse reaction or lack of efficacy
Provider must provide documentation on why switching would cause harm
Documentation required explaining why required medication is unsuitable
Dosage/Quantity Limit Exception
Dosage/Quantity Limit exceptions:
Documentation may be required
Off-Label Use Exception
Off-label (FDA indications) exceptions:
Request will be evaluated for sufficient evidence in the medical literature or compendia
What Providers Must Do
Prior authorization and submission
Prior authorization is required for prescriptions subject to Washington State utilization management rules. Providers should contact the Aetna Pharmacy Precertification Unit (Non‑Specialty 1-800-294-5979 or Specialty 1-866-814-5506) or submit the completed prior authorization form by fax (Non‑Specialty 1-877-269-9916; Specialty 1-866-249-6155), online at www.availity.com, by phone for fastest service (1-855-240-0535, Monday–Friday, 8 a.m. to 6 p.m. Central), or by mail to CVS Caremark, 1300 East Campbell Road, Richardson, TX 75081.
- Use the applicable prior authorization (PA) form when requesting an exception.
- For questions or fastest handling call 1-855-240-0535 (Mon–Fri, 8 a.m.–6 p.m. CT).
Step therapy exception criteria
An exception to step therapy, substitution, non‑formulary or tier requirements may be granted when the provider documents any of the following: intolerance or contraindication to the required drug; prior trial of the required drug with an adverse reaction or lack of effectiveness; that switching to the required drug may cause adverse reactions or negative effects; or that the required drug is not in the patient’s best interest with supporting rationale.
- Document intolerance/contraindication to the medication required to be used or tried first.
- Provide evidence of prior trial and adverse reaction or treatment failure with the required drug.
- Explain why switching would cause harm or is not in the patient’s best interest (adverse effects, interactions, adherence issues).
Required documentation
Providers must complete and submit the applicable prior authorization or exception form and supply supporting documentation demonstrating intolerance/contraindication, prior adverse reaction or lack of efficacy, clinical justification for not using required drugs, dose rationale when exceeding limits, or evidence supporting off‑label use.
- Include documentation showing prior trial and adverse reaction or ineffective response when applicable.
- Provide clinical rationale and literature/compendia evidence for off‑label indications.
- When requesting dosage/quantity exceptions, document why the requested dose is clinically necessary for the patient’s treatment plan.
Denial triggers
Requests may be rejected if the prescription does not meet utilization management rules such as formulary status, step therapy/substitution requirements, dosage/quantity limits, or required substitutions; rejected prescriptions require submission of a provider‑initiated exception request.
- If a prescription is rejected, the provider must complete and submit the applicable PA form to request an exception.
- Tier or brand‑penalty exceptions require submission of the corresponding exception form.
Key Terms and Exceptions
Scope and Purpose
This policy documents administrative utilization management (UM) workflows and exception processes that apply to Washington State fully insured Aetna members. It does not provide disease‑specific clinical guidance; rather, it explains when and how exceptions to UM rules — including formulary, step therapy, dosage/quantity limits, substitutions, non‑formulary/tier, and off‑label/FDA indication restrictions — may be requested and evaluated.
When a prescription is subject to UM rules and is rejected, the member's provider may request an exception or prior authorization. Providers should follow the administrative submission pathways listed in this document (phone, fax, online via Availity, or mail) and provide supporting documentation demonstrating one of the allowable exception criteria (for example: intolerance or contraindication, prior adverse reaction or treatment failure, clinical risk from switching, or other rationale that the required drug is not in the patient’s best interest).
Requests for exceptions based on dosage/quantity must document that the requested dosing is clinically necessary for the patient’s treatment plan. Requests for off‑label use must include evidence from medical literature or recognized compendia to support use outside the FDA‑approved indication. Aetna (via CVS Caremark) will review submitted information and determine whether the exception meets the requirements for coverage; medical necessity requirements may still apply.
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