Auth57 · Specialty PA Pack

Neurology

For the neurologist managing MS and migraine therapies — coverage, criteria, and appeals across all 51 states.

See a free state →Unlock all 51 states →

Structured rules

1,002

PA-required

99%

Appeal layer

51/51

Criteria docs

44/51

The breadth · all 51 jurisdictions

Every state, quantified for neurology

State	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	23	100%	✓	6
COColorado	91.8%	21	95%	✓	10
OHOhio	77.7%	23	100%	✓	14
All states · A–Z
AKAlaska	—	13	100%	✓	2
ALAlabama	—	21	100%	✓	6
ARArkansas	—	23	100%	✓	2
AZArizona	—	21	100%	✓	6
CACalifornia	—	23	96%	✓	7
CTConnecticut	—	21	100%	✓	3
DCDistrict of Columbia	—	21	95%	✓	9
DEDelaware	—	20	100%	✓	3
FLFlorida	—	21	100%	✓	—
GAGeorgia	—	23	96%	✓	12
HIHawaii	—	21	95%	✓	5
IAIowa	—	21	100%	✓	6
IDIdaho	—	15	100%	✓	1
ILIllinois	—	20	100%	✓	—
INIndiana	—	21	100%	✓	2
KSKansas	—	20	100%	✓	11
KYKentucky	—	23	100%	✓	3
LALouisiana	—	19	100%	✓	9
MAMassachusetts	—	17	100%	✓	1
MDMaryland	—	19	95%	✓	9
MEMaine	—	19	100%	✓	3
MIMichigan	—	19	100%	✓	6
MNMinnesota	—	15	100%	✓	2
MOMissouri	—	25	100%	✓	1
MSMississippi	—	23	100%	✓	8
MTMontana	—	15	100%	✓	2
NCNorth Carolina	—	23	100%	✓	6
NDNorth Dakota	—	15	100%	✓	—
NENebraska	—	19	100%	✓	3
NHNew Hampshire	—	19	100%	✓	—
NJNew Jersey	—	19	100%	✓	3
NMNew Mexico	—	15	100%	✓	3
NVNevada	—	19	100%	✓	16
NYNew York	—	21	100%	✓	3
OKOklahoma	—	23	100%	✓	—
OROregon	—	22	95%	✓	3
PAPennsylvania	—	19	100%	✓	8
RIRhode Island	—	15	100%	✓	—
SCSouth Carolina	—	21	100%	✓	7
SDSouth Dakota	—	13	100%	✓	—
TNTennessee	—	21	100%	✓	4
TXTexas	—	23	100%	✓	39
UTUtah	—	21	100%	✓	11
VAVirginia	—	23	96%	✓	5
VTVermont	—	13	100%	✓	6
WIWisconsin	—	21	100%	✓	3
WVWest Virginia	—	16	100%	✓	1
WYWyoming	—	15	100%	✓	5

Deep dive· Washington

Washington — neurology, 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%

MS disease-modifying therapiesPA required▲ Most difficult
Switch?PA required for non-preferred agents
Non-preferred agents (Ocrevus, Kesimpta, Briumvi, Copaxone, Aubagio, Vumerity, Mayzent, Mavenclad, Tysabri) require PA + specialty pharmacy on this plan's PDL; preferred agents in the class are open. Your patient's established therapy supports medical necessity.
Document
WA Apple Health PDL (Integrated Managed Care): preferred = generic DMTs (dimethyl fumarate, teriflunomide, fingolimod, glatiramer); non-preferred (Ocrevus, Kesimpta, Briumvi, Copaxone, Aubagio, Vumerity, Mayzent, Mavenclad, Tysabri) — PA + specialty pharmacy (SP). Switching to a brand agent needs PA; generic in-class trial usually clears it.
Submit to
the plan · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KNon-preferredGlatiramer5KCopaxone5KNon-preferredGlatopa5KAvonex4KFingolimod3KOcrevus3KNon-preferredVumerity3KNon-preferredAubagio2KNon-preferredTecfidera2KRebif2KMavenclad1KNon-preferredZeposia1KAmpyra1KBetaseron1KMayzent849Non-preferred
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migrainePA required▲ Most difficult
Switch?PA required for non-preferred agents
Non-preferred agents (Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Ubrelvy, Vyepti, Zavzpret) require PA + quantity limit on this plan's PDL; preferred agents in the class are open. Your patient's established therapy supports medical necessity.
Document
WA Apple Health PDL (Integrated Managed Care): CGRP agents are all non-preferred (Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Ubrelvy, Vyepti, Zavzpret) — PA + quantity limit (QL) required; no preferred in-class alternative, so a switch within the class still needs PA.
Submit to
the plan · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
BrandsAll non-preferred · PA
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).

commercial regulated

MS disease-modifying therapiesUnitedHealthcarePA 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). CNS-multiple sclerosis; all agents carry PA+QL+SP (MAVENCLAD adds ST) [e.g. AVONEX, KESIMPTA, MAVENCLAD, MAYZENT]
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
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineUnitedHealthcarePA 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). Antimigraine-migraines; CGRP agents (AIMOVIG, NURTEC, QULIPTA, UBRELVY, ZAVZPRET) carry PA+ST+QL; triptans QL only [e.g. AIMOVIG, EMGALITY, NURTEC, QULIPTA]
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
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineAetna (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. CGRP monoclonal antibodies, specialty PA/ST [e.g. AIMOVIG, EMGALITY, AJOVY (CGRP mAbs)]
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
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
MS disease-modifying therapiesCignaPA 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). MS DMTs SP, injectables/orals PA (generics SP only) [e.g. AVONEX, KESIMPTA, MAYZENT, VUMERITY]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineAnthem 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. CGRP receptor antagonist monoclonal antibodies: PA + QL [e.g. EMGALITY galcanezumab, CGRP monoclonal antibodies]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
MS disease-modifying therapiesAnthem 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. MS agents (interferons, NRF2, pyrimidine synthesis, K-channel blockers, oral): PA + SP; monoclonal abs vary [e.g. teriflunomide, dimethyl fumarate, interferon beta, TYSABRI natalizumab]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineCignaPA 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). CGRP mAbs and gepants carry PA [e.g. AIMOVIG, AJOVY, EMGALITY, NURTEC ODT]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).

part d

CGRP inhibitors · migraineCentenePA 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
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
MS disease-modifying therapiesCentenePA 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
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineUnitedhealthcarePA 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
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
MS disease-modifying therapiesUnitedhealthcarePA 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
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineHumanaPA 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
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
MS disease-modifying therapiesHumanaPA 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
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
MS disease-modifying therapiesCignaPA 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
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineCignaPA 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
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineAetnaPA 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
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
MS disease-modifying therapiesAetnaPA 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
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineKaiserPA 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
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).
MS disease-modifying therapiesKaiserPA 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
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).

commercial qhp

MS disease-modifying therapiesMolina 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. MS agents, interferons, and pyrimidine-synthesis inhibitor all PA
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Dimethyl Fumarate8KTeriflunomide8KKesimpta7KGlatiramer5KCopaxone5KGlatopa5KAvonex4KFingolimod3KOcrevus3KVumerity3KAubagio2KTecfidera2KRebif2KMavenclad1KZeposia1KAmpyra1KBetaseron1KMayzent849
# = Part D patients (Medicare CY2023; infused agents read low).
CGRP inhibitors · migraineMolina 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. Ubrelvy/Ajovy/Emgality (gepants + CGRP mAbs) carry PA
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Nurtec105KUbrelvy83KEmgality61KAimovig56KQulipta45KAjovy24KZavzpret3KVyepti2K
# = Part D patients (Medicare CY2023; infused agents read low).

If denied in Washington

📨 Office of Administrative Hearings (OAH)

Unlock the full pack

Full criteria, sources & appeal paths — all 51 states.

You’ve seen the breadth and one state in full. The complete Neurologypack — 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.