Auth57 · Specialty PA Pack
Infectious Disease
For the ID specialist on antiretrovirals, Hep C, and antifungals — prior auth and appeals, mapped nationwide.
Structured rules
1,835
PA-required
63%
Appeal layer
51/51
Criteria docs
51/51
The breadth · all 51 jurisdictions
Every state, quantified for infectious disease
| State | Rules | PA-required | Appeal | Criteria docs |
|---|---|---|---|---|
| AKAlaska | 26 | 65% | ✓ | 5 |
| ALAlabama | 38 | 66% | ✓ | 10 |
| ARArkansas | 40 | 65% | ✓ | 13 |
| AZArizona | 38 | 66% | ✓ | 12 |
| CACalifornia | 40 | 55% | ✓ | 7 |
| COColorado | 38 | 61% | ✓ | 15 |
| CTConnecticut | 38 | 66% | ✓ | 4 |
| DCDistrict of Columbia | 38 | 61% | ✓ | 12 |
| DEDelaware | 38 | 66% | ✓ | 7 |
| FLFlorida | 38 | 66% | ✓ | 7 |
| GAGeorgia | 41 | 63% | ✓ | 34 |
| HIHawaii | 38 | 58% | ✓ | 11 |
| IAIowa | 38 | 66% | ✓ | 18 |
| IDIdaho | 29 | 62% | ✓ | 12 |
| ILIllinois | 38 | 66% | ✓ | 6 |
| INIndiana | 38 | 68% | ✓ | 10 |
| KSKansas | 37 | 65% | ✓ | 13 |
| KYKentucky | 41 | 66% | ✓ | 6 |
| LALouisiana | 35 | 66% | ✓ | 18 |
| MAMassachusetts | 32 | 63% | ✓ | 6 |
| MDMaryland | 34 | 59% | ✓ | 25 |
| MEMaine | 34 | 62% | ✓ | 7 |
| MIMichigan | 35 | 60% | ✓ | 23 |
| MNMinnesota | 29 | 59% | ✓ | 15 |
| MOMissouri | 43 | 67% | ✓ | 6 |
| MSMississippi | 40 | 65% | ✓ | 16 |
| MTMontana | 29 | 66% | ✓ | 6 |
| NCNorth Carolina | 41 | 63% | ✓ | 47 |
| NDNorth Dakota | 28 | 61% | ✓ | 8 |
| NENebraska | 35 | 66% | ✓ | 6 |
| NHNew Hampshire | 34 | 65% | ✓ | 3 |
| NJNew Jersey | 35 | 60% | ✓ | 9 |
| NMNew Mexico | 30 | 60% | ✓ | 9 |
| NVNevada | 34 | 62% | ✓ | 28 |
| NYNew York | 39 | 64% | ✓ | 26 |
| OHOhio | 42 | 71% | ✓ | 29 |
| OKOklahoma | 41 | 63% | ✓ | 10 |
| OROregon | 41 | 63% | ✓ | 6 |
| PAPennsylvania | 35 | 63% | ✓ | 19 |
| RIRhode Island | 29 | 62% | ✓ | 4 |
| SCSouth Carolina | 38 | 66% | ✓ | 13 |
| SDSouth Dakota | 27 | 56% | ✓ | 4 |
| TNTennessee | 38 | 66% | ✓ | 10 |
| TXTexas | 40 | 60% | ✓ | 97 |
| UTUtah | 38 | 66% | ✓ | 26 |
| VAVirginia | 41 | 63% | ✓ | 22 |
| VTVermont | 26 | 62% | ✓ | 18 |
| WAWashington | 41 | 56% | ✓ | 16 |
| WIWisconsin | 38 | 68% | ✓ | 10 |
| WVWest Virginia | 32 | 66% | ✓ | 1 |
| WYWyoming | 29 | 66% | ✓ | 10 |
Free preview· Texas
What a fully-unlocked state looks like
medicare traditional
- hiv antiretroviralsNo PAOral ARVs covered under Part D PDP — no FFS Part B PA.
medicaid ffs
- hiv antiretrovirals(HHSC)No PATX Medicaid: ALL-PREFERRED / protected class — no PDL prior authorization. Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
- hepatitis c daaPA requiredTX Medicaid PDL: non-preferred agents require PA (step therapy). Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
part d
- hiv antiretroviralsNo PAFEDERAL PROTECTED CLASS. Plans must cover all or substantially all HIV ARVs without restrictive PA.
- antifungals systemic(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- hiv antiretrovirals(Centene)No PACentene Part D (CMS formulary file, plan-grounded).
- antifungals systemic(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- hiv antiretrovirals(Unitedhealthcare)No PAUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- hiv antiretrovirals(Humana)No PAHumana Part D (CMS formulary file, plan-grounded).
- antifungals systemic(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- hiv antiretrovirals(Cigna)No PACigna Part D (CMS formulary file, plan-grounded).
- antifungals systemic(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- antifungals systemic(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- hiv antiretrovirals(Aetna)No PAAetna Part D (CMS formulary file, plan-grounded).
medicare advantage
- hiv antiretroviralsNo PAHIV antiretrovirals are a Medicare Part D protected class (42 CFR 423.120(b)(2)(vi)); CMS prohibits prior authorization and step therapy on antiretrovirals (no new-start exception). PA not required.
dual eligible
- hiv antiretroviralsNo PAPart D primary — protected class, broad access. LIS eliminates cost-sharing.
medicaid mco
- hiv antiretrovirals(TX Medicaid)No PAstep therapymust not impede access to treatment
commercial regulated
- antifungals systemic(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). Antifungals-fungal infections; mostly QL but JUBLIA (PA,ST) and VIVJOA (PA) carry PA [e.g. fluconazole, itraconazole, terbinafine, JUBLIA]
- hepatitis c daa(UnitedHealthcare)PA requiredUnitedHealthcare 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]
- hiv antiretrovirals(UnitedHealthcare)No PAUnitedHealthcare commercial (Advantage 3-Tier). HIV ARVs within Antivirals heading; carry QL only (no PA); tenofovir DF carries H-PA preventive/PrEP flag, not standard PA [e.g. BIKTARVY, DOVATO, GENVOYA, TRIUMEQ]
- hepatitis c daa(Cigna)PA requiredCigna commercial (Advantage 3-Tier). HCV direct-acting antivirals SP+PA [e.g. EPCLUSA, HARVONI, VOSEVI, ZEPATIER]
- antifungals systemic(Cigna)PA requiredCigna commercial (Advantage 3-Tier). oral azoles mostly open; CRESEMBA/VIVJOA carry PA [e.g. fluconazole, itraconazole, CRESEMBA, VIVJOA]
- hiv antiretrovirals(Cigna)PA requiredCigna commercial (Advantage 3-Tier). AIDS/HIV section; several agents carry PA (others SP/QL only) [e.g. CABENUVA, DELSTRIGO, STRIBILD, PIFELTRO]
- hepatitis c daa(Aetna (CVS Caremark))PA requiredAetna (CVS Caremark) commercial formulary. HCV DAAs, specialty, PA standard [e.g. MAVYRET, EPCLUSA, sofosbuvir-velpatasvir, ZEPATIER]
- hiv antiretrovirals(Aetna (CVS Caremark))No PAAetna (CVS Caremark) commercial formulary. protected class; standard tiers, generally no PA [e.g. BIKTARVY, TRIUMEQ, DOVATO, TIVICAY]
- antifungals systemic(Aetna (CVS Caremark))No PAAetna (CVS Caremark) commercial formulary. oral antifungals; some brands ST [e.g. fluconazole, itraconazole, terbinafine, posaconazole]
- hiv antiretrovirals(Anthem Blue Cross (Elevance))No PAAnthem Blue Cross (Elevance) commercial formulary. All HIV antiretroviral subclasses (combos, integrase, protease, NNRTI, NRTI, NRTI-nucleotide, CCR5, fusion) carry QL only - NO PA, NO ST; open [e.g. abacavir-lamivudine, raltegravir (ISENTRESS), emtricitabine, tenofovir DF]
- hepatitis c daa(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Hepatitis C agents + combinations: PA + SP [e.g. EPCLUSA sofosbuvir-velpatasvir, PEGASYS peginterferon]
- antifungals systemic(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Triazoles + glucan synthesis inhibitors carry PA; imidazoles open [e.g. BREXAFEMME ibrexafungerp, voriconazole, posaconazole (triazoles)]
commercial qhp
- antifungals systemic(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- hiv antiretrovirals(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- hepatitis c daa(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- hepatitis c daa(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Hep C agents and combinations carry PA
- hiv antiretrovirals(Molina Healthcare)No PAMolina Healthcare commercial formulary. All ARV subsections (combos/integrase/protease/NNRTI/NRTI) QL/AGE only, no PA/ST
- antifungals systemic(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Systemic triazole and one antifungal carry PA
If denied in Texas
📨 Program Support Unit (PSU)
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Full criteria, sources & appeal paths — all 51 states.
You’ve seen the breadth and one state in full. The complete Infectious Diseasepack — every state’s criteria, source citations, and step-by-step appeal instructions — is one email away.
Assembled from Auth57’s rules + criteria corpus + 51-state appeal layer. Draft data — verify against the payer’s current policy before relying.