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Infectious Disease care
Auth57 · Specialty PA Pack

Infectious Disease

For the ID specialist on antiretrovirals, Hep C, and antifungals — prior auth and appeals, mapped nationwide.

See a free state →Unlock all 51 states →
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

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%4156%✓16
COColorado91.8%3861%✓15
OHOhio77.7%4271%✓29
All states · A–Z
AKAlaska—2665%✓5
ALAlabama—3866%✓10
ARArkansas—4065%✓13
AZArizona—3866%✓12
CACalifornia—4055%✓7
CTConnecticut—3866%✓4
DCDistrict of Columbia—3861%✓12
DEDelaware—3866%✓7
FLFlorida—3866%✓7
GAGeorgia—4163%✓34
HIHawaii—3858%✓11
IAIowa—3866%✓18
IDIdaho—2962%✓12
ILIllinois—3866%✓6
INIndiana—3868%✓10
KSKansas—3765%✓13
KYKentucky—4166%✓6
LALouisiana—3566%✓18
MAMassachusetts—3263%✓6
MDMaryland—3459%✓25
MEMaine—3462%✓7
MIMichigan—3560%✓23
MNMinnesota—2959%✓15
MOMissouri—4367%✓6
MSMississippi—4065%✓16
MTMontana—2966%✓6
NCNorth Carolina—4163%✓47
NDNorth Dakota—2861%✓8
NENebraska—3566%✓6
NHNew Hampshire—3465%✓3
NJNew Jersey—3560%✓9
NMNew Mexico—3060%✓9
NVNevada—3462%✓28
NYNew York—3964%✓26
OKOklahoma—4163%✓10
OROregon—4163%✓6
PAPennsylvania—3563%✓19
RIRhode Island—2962%✓4
SCSouth Carolina—3866%✓13
SDSouth Dakota—2756%✓4
TNTennessee—3866%✓10
TXTexas—4060%✓97
UTUtah—3866%✓26
VAVirginia—4163%✓22
VTVermont—2662%✓18
WIWisconsin—3868%✓10
WVWest Virginia—3266%✓1
WYWyoming—2966%✓10
Deep dive· Washington

Washington — infectious disease, 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.
  • hiv antiretroviralsHCA WashingtonNo PA▲ Most difficult
    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
    CORRECTED 2026-06-07: WA Apple Health covers all HIV treatment + PrEP WITHOUT prior authorization since 2023-01-01 (HCA legislative report). HIV is a protected class.
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    HCA Washington · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antifungals systemicPA 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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = 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).
medicaid mco
Approved · CMS-0057-F 202588.2%across 4 payers (81.2–93.1%)
Draft · aggregatedSource ↗
  • hiv antiretroviralsHCA WashingtonNo PA▲ Most difficult
    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
    CORRECTED 2026-06-07: WA Apple Health covers all HIV treatment + PrEP WITHOUT prior authorization since 2023-01-01 (HCA legislative report). HIV is a protected class.
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    HCA Washington · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
medicare advantage
  • hiv antiretroviralsNo 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
    CORRECTED 2026-06-07: WA Apple Health covers all HIV treatment + PrEP WITHOUT prior authorization since 2023-01-01 (HCA legislative report). HIV is a protected class.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
dual eligible
  • hiv antiretroviralsNo 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
    CORRECTED 2026-06-07: WA Apple Health covers all HIV treatment + PrEP WITHOUT prior authorization since 2023-01-01 (HCA legislative report). HIV is a protected class.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
part d
  • hiv antiretroviralsNo 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
    FEDERAL PROTECTED CLASS. Broad access required — no restrictive PA.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antifungals systemicCentenePA 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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = 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).
  • antifungals systemicUnitedhealthcarePA 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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = 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).
  • antifungals systemicHumanaPA 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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = 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).
  • antifungals systemicCignaPA 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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = 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).
  • antifungals systemicAetnaPA 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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = 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).
  • 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).
  • hiv antiretroviralsCenteneNo 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
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsUnitedhealthcareNo 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
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsHumanaNo 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
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsCignaNo 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
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsAetnaNo 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
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsKaiserNo 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
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antifungals systemicKaiserNo 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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = Part D patients (Medicare CY2023; infused agents read low).
medicare traditional
  • hiv antiretroviralsNo 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
    Oral drugs under Part D PDP — no FFS Part B PA. IV/infused drugs Part B — no PA under FFS.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = 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).
  • antifungals systemicUnitedHealthcarePA 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). Antifungals-fungal infections; mostly QL but JUBLIA (PA,ST) and VIVJOA (PA) carry PA [e.g. fluconazole, itraconazole, terbinafine, JUBLIA]
    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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsAnthem Blue Cross (Elevance)No 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
    Anthem 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]
    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
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsCignaPA 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
    Cigna commercial (Advantage 3-Tier). AIDS/HIV section; several agents carry PA (others SP/QL only) [e.g. CABENUVA, DELSTRIGO, STRIBILD, PIFELTRO]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsUnitedHealthcareNo 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). 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]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = 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).
  • antifungals systemicAetna (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. oral antifungals; some brands ST [e.g. fluconazole, itraconazole, terbinafine, posaconazole]
    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
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = 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).
  • 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).
  • antifungals systemicCignaPA 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 commercial (Advantage 3-Tier). oral azoles mostly open; CRESEMBA/VIVJOA carry PA [e.g. fluconazole, itraconazole, CRESEMBA, VIVJOA]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • hiv antiretroviralsAetna (CVS Caremark)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
    Aetna (CVS Caremark) commercial formulary. protected class; standard tiers, generally no PA [e.g. BIKTARVY, TRIUMEQ, DOVATO, TIVICAY]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • antifungals systemicAnthem Blue Cross (Elevance)PA 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
    Anthem Blue Cross (Elevance) commercial formulary. Triazoles + glucan synthesis inhibitors carry PA; imidazoles open [e.g. BREXAFEMME ibrexafungerp, voriconazole, posaconazole (triazoles)]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial qhp
  • hiv antiretroviralsMolina 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. All ARV subsections (combos/integrase/protease/NNRTI/NRTI) QL/AGE 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
    ···
    Biktarvy92KDescovy30KTivicay29KDovato19KTriumeq16KGenvoya15KIsentress8KDarunavir7KCabenuva7KPifeltro5KAbacavir2KIsentress Hd1KEmtricitabine859Delstrigo796Complera700Stribild630Sunlenca596Truvada578Triumeq Pd0
    # = 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).
  • antifungals systemicMolina 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. Systemic triazole and one antifungal carry PA
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Fluconazole2157KTerbinafine457KJublia35KItraconazole16KVoriconazole13KPosaconazole11KGriseofulvin5KCresemba5KFlucytosine2KVivjoa101Noxafil84Vfend55Sporanox26Antifungal0
    # = Part D patients (Medicare CY2023; infused agents read low).
If denied in Washington
📨 Office of Administrative Hearings (OAH)
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