Washington Utilization Management and Exception Process
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Defines the utilization management rules, exception and prior authorization process, and documentation requirements for Washington State fully insured plan members seeking prescription drug coverage. Applies to providers submitting PA/exception requests to Aetna Pharmacy on behalf of covered members.
No material clinical or coverage changes in this revision.
Coverage and Exception Criteria
Exceptions for Step Therapy, Substitution, Non-Formulary Tier
Requested medication may be covered when ANY of the following exception conditions are met and documentation is provided:
Provider must document intolerance/contraindication.
Document prior trial and adverse reaction or inefficacy.
Provider must provide clinical rationale, including potential drug interactions or harms.
Provider must provide documentation explaining why the required medication will cause adverse effects or is otherwise unsuitable.
Dosage/Quantity Limitations
Dosage/Quantity Limitation Exception:
Documentation may be required to support clinical need for the requested dose/quantity.
Off-label Use Evaluation
Off-label / FDA Indication Exception:
Request will be evaluated against available evidence; medical necessity requirements may still apply.
This section summarizes the administrative coverage criteria context for Washington State fully insured plans. Requests for prescription coverage may be subject to utilization management (UM) rules including formulary placement, step therapy, dosage/quantity limitations, and substitutions. If a prescription is rejected, providers may submit an exception request by completing the applicable prior authorization form and contacting Aetna Pharmacy Precertification Unit (Non‑Specialty 1‑800‑294‑5979; Specialty 1‑866‑814‑5506), or by fax or mail as listed in the policy. Exception review will consider whether one of the specified exception conditions is met and whether supporting documentation is provided; medical necessity requirements may still apply.
There are no explicit "not medically necessary" (NMN) conditions listed in this document. However, the policy states that off‑label and other exception requests will be evaluated against available evidence and that medical necessity requirements may still apply when assessing requests for coverage outside standard UM rules.
Provider Submission, Prior Authorization, and Denial Triggers
Submit PA/exception forms to Aetna Pharmacy Precertification
Complete and submit the applicable prior authorization (PA) or exception request form when a prescription is rejected. Contact Aetna Pharmacy Precertification Unit for assistance: Non‑Specialty 1-800-294-5979; Specialty 1-866-814-5506. Fax completed forms to Non‑Specialty 1-888-836-0730 or Specialty 1-866-294-6155, or mail to Aetna Pharmacy Management, 1300 East Campbell Road, Richardson, TX 75081. Providers may also request specific forms such as a Tier Exception Form or Brand Penalty Exception Form when applicable.
- Use the applicable PA/exception form (Tier Exception Form or Brand Penalty Exception Form when relevant).
- Phone contacts: Non‑Specialty 1-800-294-5979; Specialty 1-866-814-5506.
- Fax: Non‑Specialty 1-888-836-0730; Specialty 1-866-294-6155.
- Mail: Aetna Pharmacy Management, 1300 East Campbell Road, Richardson, TX 75081.
Grounds for step therapy exception
Step therapy exceptions will be considered when documentation demonstrates one of the allowed grounds: intolerance or contraindication to the required drug, prior adverse reaction or lack of effectiveness with the required drug, changing to the required drug may cause adverse reactions or other harm, or 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 with an adverse reaction (e.g., allergy) or documentation that the drug is not effective.
- Provider determines that switching to the required drug may cause adverse reactions or negative effects (including potential drug interactions).
- Provider determines the required drug is not in the patient’s best interest and must document rationale.
Required documentation to support PA/exception
Include a completed PA/exception form plus supporting documentation relevant to the exception reason: evidence of intolerance/contraindication, records of prior adverse reaction or inefficacy, or clinical rationale showing potential harm from substitution. For dosage/quantity or off‑label requests, provide documentation or literature/compendia evidence supporting the requested dose or off‑label use.
- Completed prior authorization/exception form (use Tier Exception or Brand Penalty Exception Form when applicable).
- Documentation of intolerance or contraindication to the required drug.
- Medical records showing prior adverse reaction or lack of efficacy with the required drug.
- Clinical rationale explaining why switching would cause adverse effects or is not in the patient’s best interest (include potential drug interaction details).
- For dosage/quantity exceptions: documentation that the requested dose is clinically required for the treatment plan.
- For off‑label use: supporting medical literature or compendia evidence demonstrating clinical benefit.
Triggers that may lead to denial
A request may be denied if utilization management requirements are not met, including formulary placement, step therapy requirements, dosage/quantity limits, or substitution rules.
- Failure to meet formulary or tier requirements (no approved exception submitted).
- No documentation supporting a step therapy exception when a required trial is not completed.
- Requested dosage or quantity exceeds limits without supporting clinical documentation.
- Substitution rules: lack of justification when a non‑preferred or non‑formulary drug is requested instead of the required agent.
Key Terms and Definitions
Policy Background and Scope
Scope: This policy defines the administrative utilization management and exception/prior authorization (PA) process for providers submitting requests on behalf of members covered by Washington State fully insured Aetna plans. It outlines acceptable reasons for exceptions to formulary placement, step therapy, dosage/quantity limits, and off‑label use, and directs providers to submit a completed PA/exception form with supporting documentation to the Aetna Pharmacy Precertification Unit or via the listed fax and mailing addresses.
Administrative process summary: If a prescription is rejected, the provider may request an exception by completing and submitting the applicable prior authorization form. Contact information is provided for the Aetna Pharmacy Precertification Unit (Non‑Specialty 1‑800‑294‑5979; Specialty 1‑866‑814‑5506), fax numbers for Non‑Specialty and Specialty requests, and the mailing address for Aetna Pharmacy Management. Exception requests will be reviewed to determine whether required documentation demonstrates intolerance/contraindication, prior adverse reaction or inefficacy, risk of harm from substitution, or other clinical rationale supporting the exception; documentation may also be required to support dosage/quantity or off‑label requests.
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