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Cardiology care
Auth57 · Specialty PA Pack

Cardiology

For the cardiologist on DOACs, PCSK9s, and PAH therapy — what needs PA (often less than you'd think), and how to appeal.

See a free state →Unlock all 51 states →
Structured rules
3,924
PA-required
43%
Appeal layer
51/51
Criteria docs
49/51
The breadth · all 51 jurisdictions

Every state, quantified for cardiology

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%8940%✓11
COColorado91.8%8138%✓13
OHOhio77.7%9048%✓14
All states · A–Z
AKAlaska—4947%✓2
ALAlabama—8043%✓10
ARArkansas—9245%✓7
AZArizona—8549%✓7
CACalifornia—9138%✓8
CTConnecticut—8142%✓6
DCDistrict of Columbia—8138%✓11
DEDelaware—7844%✓4
FLFlorida—8244%✓3
GAGeorgia—9337%✓20
HIHawaii—8539%✓6
IAIowa—8444%✓11
IDIdaho—5843%✓4
ILIllinois—8041%✓1
INIndiana—8046%✓5
KSKansas—8041%✓10
KYKentucky—9042%✓4
LALouisiana—7345%✓8
MAMassachusetts—6943%✓3
MDMaryland—7238%✓12
MEMaine—7240%✓3
MIMichigan—7449%✓8
MNMinnesota—6045%✓1
MOMissouri—9646%✓4
MSMississippi—8942%✓17
MTMontana—5746%✓1
NCNorth Carolina—9247%✓20
NDNorth Dakota—5638%✓1
NENebraska—7645%✓6
NHNew Hampshire—7446%✓—
NJNew Jersey—7738%✓5
NMNew Mexico—6138%✓7
NVNevada—7341%✓18
NYNew York—8545%✓7
OKOklahoma—9348%✓4
OROregon—8843%✓5
PAPennsylvania—7442%✓14
RIRhode Island—5840%✓3
SCSouth Carolina—8043%✓8
SDSouth Dakota—5334%✓3
TNTennessee—8142%✓6
TXTexas—9047%✓62
UTUtah—8549%✓18
VAVirginia—8839%✓9
VTVermont—4943%✓10
WIWisconsin—8048%✓3
WVWest Virginia—6549%✓—
WYWyoming—5542%✓6
Deep dive· Washington

Washington — cardiology, every program

Click any state in the table above to drill into its rules, approval rates, and appeal path.

● Rules verified as-of Jun 8, 2026
Medicaid FFS · CY25
54.8%approved
Draft · aggregatedSource ↗⚠ Dental = ~78% of HCA fee-for-service PA volume and is dental-skewed; expedited EPAs aren't captured. Not representative of drug/medical PA. CY2025 data is preliminary.
Medicaid MCO · CY25
88.2%approved · 4 payers
Draft · aggregatedSource ↗
Plan
Show
medicaid ffs
Approved · CMS-0057-F 202554.8%
Draft · aggregatedSource ↗⚠ Dental = ~78% of HCA fee-for-service PA volume and is dental-skewed; expedited EPAs aren't captured. Not representative of drug/medical PA. CY2025 data is preliminary.
  • pulmonary arterial hypertensionPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    WA Medicaid PDL: non-preferred agents in this class require PA.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    WA Medicaid PDL: non-preferred agents in this class require PA.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    WA Medicaid PDL: non-preferred agents in this class require PA.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    WA Medicaid PDL: non-preferred agents in this class require PA.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial regulated
  • anticoagulants doacUnitedHealthcareNo PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). Anticoagulants-blood clots; QL only on DOACs, no PA/ST [e.g. ELIQUIS, XARELTO, dabigatran, rivaroxaban]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsUnitedHealthcareNo PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). Antiplatelets-heart attack/stroke; QL only on ticagrelor, no PA/ST [e.g. clopidogrel, ticagrelor, prasugrel, cilostazol]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacAnthem Blue Cross (Elevance)PA required▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. Direct factor Xa inhibitors: PA on some agents (Eliquis QL-only but class carries PA+ST) [e.g. rivaroxaban, SAVAYSA edoxaban, apixaban (ELIQUIS)]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsUnitedHealthcareNo PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). Statin subset within Cardiovascular heading; generics tier 1, H-PA/H preventive flags only, no standard PA/ST [e.g. atorvastatin, rosuvastatin, simvastatin, pravastatin]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionUnitedHealthcarePA required▲ Most difficult
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). Respiratory-pulmonary hypertension; all carry PA+QL+SP (TYVASO PA+SP) [e.g. ADEMPAS, OPSUMIT, TYVASO, TADLIQ]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsCignaPA required▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    Cigna commercial (Advantage 3-Tier). oral ARBs mostly open but ARBLI=PA, valsartan oral soln/DIOVAN=ST [e.g. losartan, valsartan, irbesartan, ARBLI]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsCignaNo PA▲ Most difficult
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna commercial (Advantage 3-Tier). statins open (PPACA/QL); LIPOFEN/TRICOR fibrate=ST [e.g. atorvastatin, rosuvastatin, simvastatin, pravastatin]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsCignaNo PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    Cigna commercial (Advantage 3-Tier). REPATHA listed without PA/ST in this plan [e.g. REPATHA]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsUnitedHealthcareNo PA
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). PCSK9 subset within Cardiovascular heading; REPATHA carries QL only here, no PA [e.g. REPATHA]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionCignaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Cigna commercial (Advantage 3-Tier). PAH agents in respiratory section, SP+PA [e.g. ADEMPAS, OPSUMIT, TRACLEER, TYVASO]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsAetna (CVS Caremark)PA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Aetna (CVS Caremark) commercial formulary. specialty PSP; PA + step after statins standard [e.g. REPATHA (evolocumab), PRALUENT (alirocumab)]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionAetna (CVS Caremark)PA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Aetna (CVS Caremark) commercial formulary. specialty PAH, PA standard [e.g. sildenafil (PAH), tadalafil (PAH), ambrisentan, bosentan]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacAetna (CVS Caremark)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna (CVS Caremark) commercial formulary. anticoagulants/blood thinners, brand DOACs preferred; some ST [e.g. apixaban (ELIQUIS), rivaroxaban (XARELTO), warfarin, dabigatran]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionAnthem Blue Cross (Elevance)PA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. Prostaglandin vasodilators, endothelin receptor antagonists, PDE5, sGC stimulators: PA + SP [e.g. treprostinil, ambrisentan, tadalafil (ALYQ), ADEMPAS riociguat]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsAnthem Blue Cross (Elevance)PA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. PCSK9 inhibitors carry PA + QL [e.g. alirocumab, evolocumab (REPATHA/PRALUENT)]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna commercial (Advantage 3-Tier). beta blockers open (QL only) [e.g. metoprolol er, carvedilol, atenolol, nebivolol]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsAnthem Blue Cross (Elevance)No PA
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. HMG-CoA reductase inhibitors: no PA, open [e.g. atorvastatin, rosuvastatin, simvastatin, pravastatin]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersAnthem Blue Cross (Elevance)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. Alpha-beta/cardioselective/nonselective: QL only, open [e.g. metoprolol, carvedilol, atenolol, propranolol]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsAnthem Blue Cross (Elevance)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. P2Y12/thienopyridine/platelet inhibitors: QL only, open [e.g. clopidogrel, ticagrelor, prasugrel, dipyridamole]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsAnthem Blue Cross (Elevance)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. Angiotensin II receptor antagonists + combos: QL only, open [e.g. losartan, valsartan, irbesartan, olmesartan]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna commercial (Advantage 3-Tier). ACE inhibitors open [e.g. lisinopril, enalapril, lisinopril-hctz]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna commercial (Advantage 3-Tier). DOACs/warfarin open in blood thinners section [e.g. ELIQUIS, XARELTO, dabigatran, warfarin]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna commercial (Advantage 3-Tier). antiplatelets open [e.g. clopidogrel, prasugrel, ZONTIVITY]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsAetna (CVS Caremark)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna (CVS Caremark) commercial formulary. ARBs + combos, open generics [e.g. losartan, valsartan, olmesartan, irbesartan]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersAetna (CVS Caremark)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna (CVS Caremark) commercial formulary. beta-blockers + diuretic combos, open generics [e.g. metoprolol, carvedilol, atenolol, propranolol]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsAetna (CVS Caremark)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna (CVS Caremark) commercial formulary. open generics incl ACE combos [e.g. lisinopril, enalapril, benazepril, ramipril]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsAetna (CVS Caremark)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna (CVS Caremark) commercial formulary. HMG-CoA reductase inhibitors, open generics [e.g. atorvastatin, rosuvastatin, simvastatin, pravastatin]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsAetna (CVS Caremark)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna (CVS Caremark) commercial formulary. platelet aggregation inhibitors, open generics; BRILINTA brand [e.g. clopidogrel, prasugrel, ticagrelor (BRILINTA), aspirin-dipyridamole]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsAnthem Blue Cross (Elevance)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. ACE inhibitors + combos: open [e.g. lisinopril, enalapril, benazepril, ramipril]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
part d
  • pulmonary arterial hypertensionCentenePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsCentenePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsCentenePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionUnitedhealthcarePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsUnitedhealthcarePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsUnitedhealthcarePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsHumanaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsHumanaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsHumanaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionHumanaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacHumanaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsCignaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionCignaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsCignaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionAetnaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsAetnaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsAetnaPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsKaiserPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionKaiserPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsKaiserPA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersCenteneNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsCenteneNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacCenteneNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsCenteneNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsCenteneNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacUnitedhealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsUnitedhealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsUnitedhealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersUnitedhealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsUnitedhealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersHumanaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsHumanaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsHumanaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacAetnaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsAetnaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsAetnaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsAetnaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersAetnaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • anticoagulants doacKaiserNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsKaiserNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsKaiserNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsKaiserNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersKaiserNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial qhp
  • anticoagulants doacMolina HealthcareNo PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    Molina Healthcare commercial formulary. Eliquis/Xarelto (Direct Factor Xa) QL only, no PA/ST
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Eliquis4423KXarelto1321KWarfarin854KEnoxaparin282KPradaxa139KDabigatran107KDabigatran Etexilate107KSavaysa2KLovenox392Apixaban0Rivaroxaban0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • statinsMolina HealthcarePA required▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    Molina Healthcare commercial formulary. fluvastatin ER ST plus a PA; most statins open
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Atorvastatin17825KRosuvastatin8209KSimvastatin3667KEzetimibe2410KPravastatin2343KPravastatin Sodium2343KLovastatin629KVascepa301KPitavastatin49KLivalo38KCrestor14KLipitor7KZypitamag3KZetia2KVytorin1KZocor691
    # = Part D patients (Medicare CY2023; infused agents read low).
  • ace inhibitorsMolina HealthcareNo PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
    Document
    Molina Healthcare commercial formulary. ACE Inhibitors section open, no PA/ST
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lisinopril8755KValsartan1199KIrbesartan630KBenazepril523KEnalapril465KRamipril378KCandesartan120KCaptopril17KAliskiren7KQuinapril684Altace420Zestoretic183Lotensin0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antiplateletsMolina HealthcarePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Molina Healthcare commercial formulary. P2Y12, platelet-aggregation and PAR-1 inhibitors carry PA; thienopyridines open
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Clopidogrel3407KBrilinta243KCilostazol201KPrasugrel91KPlavix3KDipyridamole3KEffient188Zontivity96Cablivi50Aspirin0Ticagrelor0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pcsk9 inhibitorsMolina HealthcarePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Molina Healthcare commercial formulary. 3 PA flags in PCSK9 inhibitor section
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ezetimibe2410KRepatha460KPraluent92KNexletol30KNexlizet27KLeqvio3KLerochol0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • pulmonary arterial hypertensionMolina HealthcarePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Molina Healthcare commercial formulary. Prostaglandin vasodilators / PAH agents carry 14 PA
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • arbsMolina HealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Molina Healthcare commercial formulary. Angiotensin II Receptor Antagonists section open
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Losartan8908KValsartan1199KOlmesartan912KEntresto795KIrbesartan630KTelmisartan336KEdarbi16KDiovan8KBenicar6KArbli0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • beta blockersMolina HealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Molina Healthcare commercial formulary. Cardioselective/non-selective/alpha-beta blockers all open
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Metoprolol11618KCarvedilol3666KAtenolol1566KPropranolol999KNebivolol348KBisoprolol286KLabetalol241KBystolic9KToprol Xl9KTenormin605Lopressor256Hemangeol0
    # = Part D patients (Medicare CY2023; infused agents read low).
If denied in Washington
📨 Office of Administrative Hearings (OAH)
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