Drug Level Detail Report

ATTENTION: This form is no longer active!! Please refer to the below links. Any further submissions using this form will not be sent to Salesforce.

· Self-funded impact reports: Please submit your request using the Commitments and Profitability Tracker (CPT).

o Click here for an overview of how to use the CPT.

o The CPT requires multifactor authentication, which must first be set up.

· Fully insured impact reports: Please submit your request to the Pharmacy Ad Hoc team.

This form may be used to request client-specific impact reports for customers transitioning to one of the following formularies:

Self Insured:

Aetna Standard Plan (Lead Offer)

Standard Opt Out Plan

Standard Opt Out Plan with ACSF (Advanced Control Specialty Formulary)

Advanced Control Plan

High Value Plan – 2 Tier Closed

Basic Control

Basic Control with ACSF

If you require reports illustrating the impact of planned quarterly formulary updates (e.g. ANOC), account managers may run a disruption report in Managed Care Monitor (MCM) when available.

Fully Insured Impact Report Requests will need to be submitted to the Pharmacy Ad-Hoc Team using this link. https://aetna.quickbase.com/db/bje6fjtkd?a=GenNewRecord

Request Information

Requestor's Full Name

Requestor's Email

Customer Information

Customer Name

Segment

PSU

Funding

Which population are you wanting impact for?

Client is considering Self-funding?

**If No, please request via Pharmacy Ad-Hoc**

Which population are you wanting impact for?

**Fully Insured needs to be requested via Pharmacy Ad-Hoc**

What is your current formulary?

Current Formulary and formulary requesting impact for cannot be the same

Which Self Insured Formulary are you requesting?

Utilization Management Option

Please identify the control number(s) for the SI portion of the plan.

Recent Claim Period

Custom Claim Period

Must be between 3-12 months

Contact Information