Washington Utilization Management and Exception Process
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Defines utilization management requirements, exception and prior authorization processes for prescription drug coverage for members covered by Washington State fully insured plans administered by Banner Health and Aetna Health Insurance Company. Affects prescribing providers seeking coverage exceptions and prior authorizations for nonpreferred, step therapy, dosage/quantity, or off‑label uses.
No material clinical or coverage changes in this revision.
Coverage Criteria
Step therapy / Non-formulary tier exception criteria
Consideration for receiving an exception to required utilization management (including step therapy, non‑formulary tier, substitutions) — the requested medication may be covered when ANY of the following are met and documentation provided:
Provider must document intolerance or contraindication.
Document prior trial and outcome.
Provide clinical rationale and supporting documentation.
Detailed provider explanation required.
Dosage/Quantity Limitations
Dosage/Quantity Limitations — the requested medication may be covered if:
Documentation may be required to support clinical need for the requested dose/quantity.
FDA Indications and Off-Label Use
Off‑label (FDA indications) use — evaluation for coverage:
Must show sufficient clinical evidence or compendia support.
Provider Actions & Submission Requirements
Prior authorization and exception submission
Prior authorization (PA) is required for certain prescriptions for members covered by Washington State fully insured plans. Providers must submit the applicable PA form and supporting documentation to Aetna/CVS Caremark via fax, mail, or online (Availity), or contact the Aetna Pharmacy Precertification Unit for assistance.
- Phone: Aetna Pharmacy Precertification Unit Non‑Specialty 1-800-294-5979 or Specialty 1-866-814-5506
- Fax: Non‑Specialty Drug Prior Authorization 1-877-269-9916 or Specialty Drug Prior Authorization 1-866-249-6155
- Online: www.availity.com
- Mail: CVS Caremark, 1300 East Campbell Road, Richardson, TX 75081
- For fastest service call: 1-855-240-0535, Monday–Friday, 8 a.m. to 6 p.m. Central Time
Step therapy substitution exception criteria
Step therapy substitution exceptions may be approved when documentation demonstrates one of the following: intolerance or contraindication to the required drug, a prior adverse reaction or lack of efficacy with the required drug, that switching would cause harm, or when the provider determines the required drug is not in the patient’s best interest.
- Intolerance or contraindication to the medication required to be used or tried first
- Previously tried the required drug and had an adverse reaction (e.g., allergy) or documentation that the drug is not effective
- Provider determines changing to the required drug may cause adverse reactions or a negative effect
- Provider determines the required drug is not in the patient’s best interest and must document why (adverse effects, interactions, or adherence issues)
Required supporting documentation for PA or exception
When requesting a prior authorization or an exception, providers must supply supporting documentation that demonstrates the clinical reason for the request, such as evidence of intolerance/contraindication, prior adverse reaction or lack of efficacy, risk from switching, or why the required drug is not in the patient’s best interest; documentation for dosage/quantity exceptions should support clinical need for the requested dose/quantity.
- Clinical documentation of intolerance or contraindication to the required medication
- Records showing prior trial and adverse reaction or lack of efficacy with the required drug
- Clinical rationale and evidence that switching to the required drug would cause harm
- Explanation of anticipated adverse effects, drug interactions, or adherence issues if required drug used
- For dosage/quantity requests, documentation supporting need for the requested dose or quantity
Rejection risks and exception submission reminder
Requests may be rejected if prior authorization or exception criteria and required documentation are not met; if a prescription is rejected the provider may request an exception by completing and submitting the applicable PA form.
- Complete and submit the applicable prior authorization or exception form (Tier Exception Form or Brand Penalty Exception Form where applicable)
- Ensure all required supporting documentation is included to avoid rejection
Background
This policy describes the administrative utilization management (UM) processes that apply to members covered by Washington State fully insured plans administered by Banner Health and Aetna. These UM processes include formulary management, step therapy, non‑formulary/tier exceptions, dosage/quantity limitations, and substitutions. As part of the review, medical necessity requirements may still apply and will be considered during authorization decisions.
When a prescription is subject to UM and coverage is initially denied, the member’s prescribing provider may request an exception or prior authorization by submitting the applicable form and supporting documentation to Aetna/CVS Caremark. Providers can contact Aetna Pharmacy Precertification (Non‑Specialty: 1‑800‑294‑5979; Specialty: 1‑866‑814‑5506), fax PA requests (Non‑Specialty: 1‑877‑269‑9916; Specialty: 1‑866‑249‑6155), submit online via www.availity.com, or mail forms to CVS Caremark in Richardson, TX. For fastest service, providers may call 1‑855‑240‑0535 (Mon–Fri, 8 a.m.–6 p.m. CT).
Exceptions to required UM (including step therapy or non‑formulary tier) are considered when documentation shows one or more of the following: intolerance or contraindication to the required drug; a prior adverse reaction or lack of efficacy to the required drug; clinical rationale that switching to the required drug poses risk of adverse effects; or when the provider documents that the required drug is not in the patient’s best interest (including potential interactions or adherence concerns). Requests for dosage/quantity exceptions must show that the requested dose is clinically required, and off‑label use requests will be evaluated for sufficient supporting evidence in the medical literature or compendia.
Definitions
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