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Gastroenterology care
Auth57 · Specialty PA Pack

Gastroenterology

For the GI practice running IBD biologics and Hep C therapy — what needs prior auth, and how to win the appeal.

See a free state →Unlock all 51 states →
Structured rules
1,955
PA-required
99%
Appeal layer
51/51
Criteria docs
47/51
The breadth · all 51 jurisdictions

Every state, quantified for gastroenterology

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%44100%✓9
COColorado91.8%4093%✓11
OHOhio77.7%46100%✓12
All states · A–Z
AKAlaska—26100%✓3
ALAlabama—42100%✓4
ARArkansas—44100%✓5
AZArizona—40100%✓2
CACalifornia—4691%✓7
CTConnecticut—41100%✓4
DCDistrict of Columbia—4193%✓4
DEDelaware—39100%✓4
FLFlorida—42100%✓2
GAGeorgia—4593%✓11
HIHawaii—4288%✓5
IAIowa—39100%✓7
IDIdaho—30100%✓2
ILIllinois—40100%✓3
INIndiana—39100%✓3
KSKansas—41100%✓18
KYKentucky—45100%✓5
LALouisiana—37100%✓8
MAMassachusetts—34100%✓1
MDMaryland—3692%✓6
MEMaine—36100%✓4
MIMichigan—3897%✓13
MNMinnesota—30100%✓4
MOMissouri—49100%✓3
MSMississippi—45100%✓10
MTMontana—28100%✓2
NCNorth Carolina—45100%✓16
NDNorth Dakota—29100%✓1
NENebraska—36100%✓2
NHNew Hampshire—36100%✓—
NJNew Jersey—37100%✓2
NMNew Mexico—30100%✓—
NVNevada—36100%✓11
NYNew York—42100%✓12
OKOklahoma—46100%✓2
OROregon—4393%✓3
PAPennsylvania—38100%✓14
RIRhode Island—28100%✓1
SCSouth Carolina—40100%✓6
SDSouth Dakota—26100%✓—
TNTennessee—41100%✓3
TXTexas—46100%✓73
UTUtah—42100%✓16
VAVirginia—4493%✓4
VTVermont—25100%✓1
WIWisconsin—40100%✓2
WVWest Virginia—33100%✓—
WYWyoming—27100%✓5
Deep dive· Washington

Washington — gastroenterology, 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.
  • jak 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
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaPA 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
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial regulated
  • hepatitis c daaUnitedHealthcarePA required▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + 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
    UnitedHealthcare commercial (Advantage 3-Tier). Hep C DAAs within Antivirals heading; all carry PA+QL+SP (HARVONI/LEDIPASVIR-SOFOSBUVIR add ST) [e.g. EPCLUSA, HARVONI, MAVYRET, VOSEVI]
    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
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsUnitedHealthcarePA required▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + 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
    UnitedHealthcare commercial (Advantage 3-Tier). IL inhibitor subset within Immunological heading; all carry PA+QL+SP (some +ST) [e.g. COSENTYX, SKYRIZI, BIMZELX, OMVOH]
    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
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf inhibitorsAetna (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 + 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
    Aetna (CVS Caremark) commercial formulary. self-administered autoimmune biologics + JAK (TNF/IL/JAK), specialty PSP, PA/ST [e.g. HUMIRA, ENBREL, DUPIXENT, SKYRIZI]
    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
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsAnthem 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. Interleukin antagonists + costimulation modulators: PA/SP (some ST) [e.g. STELARA, SKYRIZI, ustekinumab, ORENCIA abatacept]
    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
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf inhibitorsUnitedHealthcarePA 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). TNF inhibitor subset within Immunological heading; all carry PA+QL+SP [e.g. HUMIRA, ENBREL, CIMZIA, SIMPONI]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak inhibitorsUnitedHealthcarePA 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). JAK inhibitor subset within Immunological heading; all carry PA+QL+SP [e.g. RINVOQ, XELJANZ, XELJANZ XR, OLUMIANT]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaCignaPA 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). HCV direct-acting antivirals SP+PA [e.g. EPCLUSA, HARVONI, VOSEVI, ZEPATIER]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf inhibitorsCignaPA 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). TNF inhibitors SP+PA in pain/inflammatory section [e.g. HUMIRA, ENBREL, INFLECTRA, CIMZIA]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak inhibitorsCignaPA 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). JAK/TYK2 inhibitors SP+PA [e.g. RINVOQ, XELJANZ, OLUMIANT, SOTYKTU]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsCignaPA 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). IL-17/23/etc biologics SP+PA [e.g. COSENTYX, TALTZ, SKYRIZI, TREMFYA]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaAetna (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. HCV DAAs, specialty, PA standard [e.g. MAVYRET, EPCLUSA, sofosbuvir-velpatasvir, ZEPATIER]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf inhibitorsAnthem 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. Soluble TNF receptor + anti-TNF monoclonals: PA/SP [e.g. ENBREL, HUMIRA, etanercept, adalimumab]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak inhibitorsAnthem 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. Antirheumatic JAK + oncology JAK: PA/SP [e.g. RINVOQ, XELJANZ, upadacitinib, JAKAFI ruxolitinib]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaAnthem 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. Hepatitis C agents + combinations: PA + SP [e.g. EPCLUSA sofosbuvir-velpatasvir, PEGASYS peginterferon]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
part d
  • jak 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
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf 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
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaCentenePA 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
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsCentenePA 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
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak 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
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsUnitedhealthcarePA 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
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaUnitedhealthcarePA 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
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf 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
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak 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
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsHumanaPA 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
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaHumanaPA 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
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf 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
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf 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
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak 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
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaCignaPA 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
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsCignaPA 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
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf 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
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak 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
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaAetnaPA 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
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsAetnaPA 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
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak 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
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf 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
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaKaiserPA 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
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • il inhibitors biologicsKaiserPA 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
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial qhp
  • il inhibitors biologicsMolina 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. IL-1/IL-1Ra/IL-6/IL-5/anti-IgE and GI IL antagonists all PA
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1KIlumya696Infliximab337Omvoh130Actimmune47Pyzchiva0Selarsdi0Ustekinumab0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hepatitis c daaMolina 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. Hep C agents and combinations carry PA
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Epclusa12KMavyret7KRibavirin1KPegasys1KVosevi711Harvoni497Sovaldi23Zepatier14Sofosbuvir0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • tnf 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. Anti-TNF mAbs, soluble TNF receptor, and GI TNF blockers all carry PA
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145
    # = Part D patients (Medicare CY2023; infused agents read low).
  • jak 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. Antirheumatic JAK inhibitors carry PA (5 flags)
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Rinvoq29KXeljanz19KOpzelura19KSotyktu2KOlumiant2KCibinqo536Litfulo274Leqselvi0
    # = 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.