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Endocrinology care
Auth57 · Specialty PA Pack

Endocrinology

For the endocrinologist on GLP-1s, insulin, and growth hormone — where PA bites, and exactly how to clear it.

See a free state →Unlock all 51 states →
Structured rules
1,583
PA-required
81%
Appeal layer
51/51
Criteria docs
50/51
The breadth · all 51 jurisdictions

Every state, quantified for endocrinology

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%3678%✓11
COColorado91.8%3379%✓6
OHOhio77.7%3681%✓15
All states · A–Z
AKAlaska—2186%✓4
ALAlabama—3382%✓6
ARArkansas—3681%✓8
AZArizona—3382%✓5
CACalifornia—3678%✓11
CTConnecticut—3379%✓11
DCDistrict of Columbia—3379%✓8
DEDelaware—3382%✓4
FLFlorida—3382%✓4
GAGeorgia—3678%✓20
HIHawaii—3376%✓9
IAIowa—3382%✓13
IDIdaho—2479%✓10
ILIllinois—3281%✓2
INIndiana—3382%✓8
KSKansas—3382%✓11
KYKentucky—3678%✓4
LALouisiana—3083%✓17
MAMassachusetts—2781%✓14
MDMaryland—3080%✓22
MEMaine—3080%✓4
MIMichigan—3083%✓13
MNMinnesota—2483%✓2
MOMissouri—3879%✓5
MSMississippi—3681%✓9
MTMontana—2483%✓4
NCNorth Carolina—3681%✓31
NDNorth Dakota—2483%✓8
NENebraska—3083%✓4
NHNew Hampshire—3083%✓—
NJNew Jersey—3080%✓3
NMNew Mexico—2475%✓5
NVNevada—2979%✓22
NYNew York—3379%✓9
OKOklahoma—3681%✓3
OROregon—3681%✓3
PAPennsylvania—3080%✓23
RIRhode Island—2483%✓3
SCSouth Carolina—3281%✓6
SDSouth Dakota—2181%✓3
TNTennessee—3382%✓6
TXTexas—3681%✓54
UTUtah—3382%✓16
VAVirginia—3678%✓20
VTVermont—2181%✓8
WIWisconsin—3382%✓2
WVWest Virginia—2785%✓2
WYWyoming—2483%✓9
Deep dive· Washington

Washington — endocrinology, 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.
  • growth hormonePA 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
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsPA 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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsPA 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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial regulated
  • insulinsUnitedHealthcarePA 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
    UnitedHealthcare commercial (Advantage 3-Tier). Diabetes-Insulin; almost all QL only, but NOVOLIN R FLEXPEN carries ST; no true PA [e.g. HUMALOG, HUMULIN, LANTUS, insulin lispro]
    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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneAnthem 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 + specialty pharmacy + 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. Growth hormones: PA + SP (some ST) [e.g. OMNITROPE somatropin, growth hormones]
    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
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneUnitedHealthcarePA 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). Hormonal-Other; growth hormones (NGENLA, NORDITROPIN, OMNITROPE, SKYTROFA) and GnRH agents (ORIAHNN, ORILISSA) all carry PA+QL(+SP) [e.g. NGENLA, NORDITROPIN FLEXPRO, OMNITROPE, SKYTROFA]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsAetna (CVS Caremark)PA 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
    Aetna (CVS Caremark) commercial formulary. incretin mimetic agents + combos, PA/ST (diabetes indication edits) [e.g. OZEMPIC, MOUNJARO, TRULICITY, RYBELSUS]
    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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsUnitedHealthcarePA 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
    UnitedHealthcare commercial (Advantage 3-Tier). GLP-1 (and GLP-1/GIP) agonists within Diabetes-Non-insulin; all carry PA+QL [e.g. OZEMPIC, MOUNJARO, TRULICITY, RYBELSUS]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneCignaPA 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). somatropins SP+PA in hormonal agents section [e.g. GENOTROPIN, OMNITROPE, NGENLA, NorditropI]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsCignaPA 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
    Cigna commercial (Advantage 3-Tier). GLP-1 agonists carry PA+QL [e.g. OZEMPIC, MOUNJARO, TRULICITY, RYBELSUS]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsAetna (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. insulins, preferred brands; ST/formulary-preferred [e.g. insulin glargine, insulin lispro, insulin aspart, HUMALOG]
    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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneAetna (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. human growth hormones, specialty PA [e.g. somatropin (NORDITROPIN, GENOTROPIN, HUMATROPE)]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsAnthem 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. Incretin mimetic GLP-1 receptor agonists: PA + QL [e.g. liraglutide, dulaglutide, exenatide]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsAnthem 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. Human insulin subclass carries PA + QL in this listing [e.g. HUMALOG, insulin lispro, insulin (human)]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsCignaNo 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). insulins open, QL only [e.g. LANTUS, HUMALOG, TRESIBA, INSULIN LISPRO]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
part d
  • growth hormoneCentenePA 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
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsCentenePA 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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneUnitedhealthcarePA 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
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsUnitedhealthcarePA 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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsHumanaPA 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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneHumanaPA 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
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneCignaPA 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
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsCignaPA 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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneAetnaPA 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
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsAetnaPA 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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsAetnaPA 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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneKaiserPA 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
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsKaiserPA 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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsCenteneNo 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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsUnitedhealthcareNo 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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsHumanaNo 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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsCignaNo 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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • insulinsKaiserNo 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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial qhp
  • insulinsMolina 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. Human Insulin section only QL/MAIL/$35 cap, 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
    ···
    Lantus1687KInsulin1074KHumalog705KNovolog666KTresiba572KBasaglar424KInsulin Lispro408KToujeo324KHumulin311KLevemir262KNovolin177KInsulin Aspart168KFiasp160KAdmelog67KInsulin Degludec50KInsulin Glargine37KLyumjev31KApidra3K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • glp1 agonistsMolina 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. Ozempic/Trulicity/Rybelsus/liraglutide all carry 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
    ···
    Ozempic1952KMounjaro894KJanuvia828KTrulicity788KRybelsus310KVictoza104KSoliqua59KBydureon38KGlyxambi29KLiraglutide24KSitagliptin6KByetta3KExenatide0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • growth hormoneMolina 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. Growth Hormones section 4 PA flags
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Genotropin1KNorditropin779Omnitrope702Orilissa511Humatrope285Oriahnn49Ngenla0Skytrofa0Zomacton0
    # = Part D patients (Medicare CY2023; infused agents read low).
If denied in Washington
📨 Office of Administrative Hearings (OAH)
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Assembled from Auth57’s rules + criteria corpus + 51-state appeal layer. Draft data — verify against the payer’s current policy before relying.