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Oncology care
Auth57 · Specialty PA Pack

Oncology

For the oncology team on oral chemo and supportive care — prior auth and appeals, mapped nationwide.

See a free state →Unlock all 51 states →
Structured rules
907
PA-required
89%
Appeal layer
51/51
Criteria docs
51/51
The breadth · all 51 jurisdictions

Every state, quantified for oncology

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%1989%✓13
COColorado91.8%1889%✓2
OHOhio77.7%2195%✓10
All states · A–Z
AKAlaska—1486%✓6
ALAlabama—1889%✓1
ARArkansas—1989%✓7
AZArizona—1989%✓6
CACalifornia—2588%✓15
CTConnecticut—1889%✓1
DCDistrict of Columbia—1889%✓3
DEDelaware—1889%✓4
FLFlorida—1989%✓10
GAGeorgia—1989%✓17
HIHawaii—1989%✓14
IAIowa—1889%✓8
IDIdaho—1587%✓4
ILIllinois—1889%✓9
INIndiana—1889%✓8
KSKansas—1889%✓9
KYKentucky—1989%✓10
LALouisiana—1788%✓13
MAMassachusetts—1788%✓14
MDMaryland—1788%✓8
MEMaine—1788%✓4
MIMichigan—1883%✓7
MNMinnesota—1587%✓2
MOMissouri—2090%✓4
MSMississippi—1989%✓8
MTMontana—1587%✓1
NCNorth Carolina—1989%✓44
NDNorth Dakota—1587%✓3
NENebraska—1889%✓7
NHNew Hampshire—1788%✓2
NJNew Jersey—1788%✓5
NMNew Mexico—1688%✓2
NVNevada—1788%✓15
NYNew York—2090%✓14
OKOklahoma—2090%✓3
OROregon—1989%✓5
PAPennsylvania—1788%✓14
RIRhode Island—1587%✓2
SCSouth Carolina—1889%✓7
SDSouth Dakota—1587%✓1
TNTennessee—1889%✓9
TXTexas—2186%✓80
UTUtah—1889%✓5
VAVirginia—1989%✓6
VTVermont—1486%✓20
WIWisconsin—1889%✓10
WVWest Virginia—1688%✓4
WYWyoming—1587%✓1
Deep dive· Washington

Washington — oncology, 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 mco
Approved · CMS-0057-F 202588.2%across 4 payers (81.2–93.1%)
Draft · aggregatedSource ↗
  • oncology oralPA 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
    diagnosis; oncologist attestation
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial regulated
  • oncology oralUnitedHealthcarePA 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). Antineoplastics-cancer; nearly all brand oral oncolytics carry PA+QL+SP; generics (anastrozole, tamoxifen) H-PA only [e.g. ALECENSA, CALQUENCE, LYNPARZA, TAGRISSO]
    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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralCignaPA required▲ Most difficult
    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). oral oncolytics SP+PA throughout cancer section [e.g. IBRANCE, IMBRUVICA, VERZENIO, XTANDI]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralAetna (CVS Caremark)PA required▲ Most difficult
    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. oral antineoplastics (alkylating/antimetabolites/BCL-2/kinase/proteasome/topoisomerase), specialty PA [e.g. kinase inhibitors, VENCLEXTA, temozolomide, imatinib]
    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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralAnthem 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. Oral antineoplastics (ALK/BCR-ABL/BRAF/BTK/EGFR/MEK/mTOR/CDK/PARP/PI3K/multikinase/immunomodulators/antimetabolites/LHRH): PA + SP [e.g. capecitabine, IMBRUVICA ibrutinib, TAFINLAR dabrafenib, IBRANCE palbociclib]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology supportiveAetna (CVS Caremark)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
    Aetna (CVS Caremark) commercial formulary. protective/supportive oncology agents [e.g. leucovorin, mesna, protective agents]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ondansetron5206KLeucovorin28KProcrit25KDronabinol20KAranesp6KAprepitant5KEpogen4KNeulasta4KGranisetron4KGranix2KNeupogen1KLeukine89Emend15Mesna15Tecvayli13Elrexfio0Epkinly0Talvey0
    # = Part D patients (Medicare CY2023; infused agents read low).
dual eligible
  • oncology oralPA 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
    Part D primary. Part D protected class. Broad access required. LIS eliminates cost-sharing.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
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.
  • oncology oralPA 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
    Diagnosis required; Oncologist attestation required
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
medicare advantage
  • oncology oralPA 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
    Part D protected class. Broad access required.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
medicare traditional
  • oncology oralNo 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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
part d
  • oncology oralCentenePA 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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralUnitedhealthcarePA 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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralHumanaPA 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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralCignaPA 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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralAetnaPA 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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralKaiserPA 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
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology oralNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    FEDERAL PROTECTED CLASS. Broad access required.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial qhp
  • oncology oralMolina 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. Antineoplastics block: 86 PA flags across kinase inhibitors etc
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21
    # = Part D patients (Medicare CY2023; infused agents read low).
  • oncology supportiveMolina 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. ESAs and TPO receptor agonists carry PA; 5-HT3 antiemetic 1 PA
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Ondansetron5206KLeucovorin28KProcrit25KDronabinol20KAranesp6KAprepitant5KEpogen4KNeulasta4KGranisetron4KGranix2KNeupogen1KLeukine89Emend15Mesna15Tecvayli13Elrexfio0Epkinly0Talvey0
    # = Part D patients (Medicare CY2023; infused agents read low).
If denied in Washington
📨 Office of Administrative Hearings (OAH)
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Full criteria, sources & appeal paths — all 51 states.

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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.