Auth57 · Specialty PA Pack

Psychiatry / Behavioral Health

For the psychiatrist prescribing stimulants, antipsychotics, and antidepressants — coverage and appeals, every plan.

See a free state →Unlock all 51 states →

Structured rules

3,219

PA-required

70%

Appeal layer

51/51

Criteria docs

48/51

The breadth · all 51 jurisdictions

Every state, quantified for psychiatry / behavioral health

State	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	73	73%	✓	9
COColorado	91.8%	67	66%	✓	3
OHOhio	77.7%	74	74%	✓	23
All states · A–Z
AKAlaska	—	44	68%	✓	2
ALAlabama	—	65	72%	✓	12
ARArkansas	—	74	73%	✓	3
AZArizona	—	68	74%	✓	9
CACalifornia	—	74	62%	✓	18
CTConnecticut	—	66	71%	✓	2
DCDistrict of Columbia	—	67	66%	✓	11
DEDelaware	—	67	73%	✓	3
FLFlorida	—	68	72%	✓	4
GAGeorgia	—	74	64%	✓	27
HIHawaii	—	68	63%	✓	11
IAIowa	—	68	72%	✓	7
IDIdaho	—	50	66%	✓	4
ILIllinois	—	66	71%	✓	4
INIndiana	—	64	72%	✓	7
KSKansas	—	65	72%	✓	15
KYKentucky	—	74	73%	✓	5
LALouisiana	—	60	70%	✓	10
MAMassachusetts	—	56	70%	✓	17
MDMaryland	—	59	63%	✓	12
MEMaine	—	61	70%	✓	4
MIMichigan	—	62	63%	✓	11
MNMinnesota	—	49	67%	✓	1
MOMissouri	—	76	74%	✓	8
MSMississippi	—	73	73%	✓	12
MTMontana	—	47	66%	✓	3
NCNorth Carolina	—	73	74%	✓	33
NDNorth Dakota	—	47	68%	✓	3
NENebraska	—	58	69%	✓	2
NHNew Hampshire	—	61	72%	✓	—
NJNew Jersey	—	60	67%	✓	3
NMNew Mexico	—	51	65%	✓	8
NVNevada	—	62	71%	✓	33
NYNew York	—	68	72%	✓	9
OKOklahoma	—	74	74%	✓	—
OROregon	—	71	68%	✓	7
PAPennsylvania	—	62	71%	✓	19
RIRhode Island	—	49	69%	✓	—
SCSouth Carolina	—	67	72%	✓	5
SDSouth Dakota	—	45	64%	✓	2
TNTennessee	—	67	73%	✓	7
TXTexas	—	74	73%	✓	59
UTUtah	—	68	74%	✓	15
VAVirginia	—	71	66%	✓	17
VTVermont	—	42	62%	✓	4
WIWisconsin	—	67	73%	✓	2
WVWest Virginia	—	55	71%	✓	1
WYWyoming	—	48	65%	✓	8

Deep dive· Washington

Washington — psychiatry / behavioral health, 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 ↗

adhd stimulantsPA required▲ 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
ADHD diagnosis; Adult patient
Step therapy
Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
Submit to
the plan · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).

medicaid ffs

Approved · CMS-0057-F 202554.8%

adhd stimulantsPA required▲ 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
ADHD stimulants require PA for adults. Generics preferred; brand/XR may require step.
Step therapy
Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
Submit to
the plan · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsPA 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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsPA 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
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsPA 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
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsPA 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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).

dual eligible

adhd stimulantsMA Part DPA 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. Brand/non-preferred stimulants may require PA under MA Part D. LIS eliminates cost-sharing.
Submit to
MA Part D · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).

medicare traditional

adhd stimulantsNo 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
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).

medicare advantage

adhd stimulantsPA 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
Brand/non-preferred stimulants may require PA under MA Part D.
Submit to
the plan · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).

part d

adhd stimulantsPA 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
Brand/non-preferred stimulants require PA on Part D.
Submit to
the plan · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesCentenePA 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
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsCentenePA 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
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsCentenePA 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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsCentenePA 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
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsCentenePA 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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsUnitedhealthcarePA 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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsUnitedhealthcarePA 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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesUnitedhealthcarePA 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
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsUnitedhealthcarePA 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
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsUnitedhealthcarePA 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
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsHumanaPA 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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsHumanaPA 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
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsHumanaPA 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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesHumanaPA 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
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsCignaPA 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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsCignaPA 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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsCignaPA 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
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsCignaPA 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
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesCignaPA 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
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsAetnaPA 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
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsAetnaPA 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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsAetnaPA 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
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesAetnaPA 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
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsAetnaPA 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
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsAetnaPA 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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsKaiserPA 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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsKaiserPA 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
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsKaiserPA 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
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsKaiserPA 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
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsKaiserPA 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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsCenteneNo 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
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsUnitedhealthcareNo 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
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsHumanaNo 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
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsHumanaNo 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
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsCignaNo 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
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesKaiserNo 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
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).

commercial regulated

atypical antipsychoticsUnitedHealthcarePA 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). Antipsychotics-mood disorders; generics QL only but CAPLYTA carries PA+ST+QL; brands REXULTI/VRAYLAR QL [e.g. aripiprazole, risperidone, quetiapine, CAPLYTA]
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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesUnitedHealthcareNo 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
UnitedHealthcare commercial (Advantage 3-Tier). Anxiolytics-anxiety; all tier 1, no PA/ST/QL [e.g. alprazolam, lorazepam, clonazepam, buspirone]
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
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsUnitedHealthcarePA 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). CNS-attention deficit; generics QL but AZSTARYS/JORNAY PM (ST,QL) and XELSTRYM (PA,QL) carry step/PA [e.g. amphetamine-dextroamphetamine, methylphenidate, lisdexamfetamine, AZSTARYS]
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
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsCignaPA 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
Cigna commercial (Advantage 3-Tier). generic atypicals open (QL); SECUADO=ST [e.g. aripiprazole, risperidone, quetiapine, CAPLYTA]
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
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsCignaPA required▲ Most difficult
Switch?PA + step therapy — a prior in-class trial usually clears it
This plan gates the class with PA + 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
Cigna commercial (Advantage 3-Tier). mixed; AUVELITY=ST, ZURZUVAE/NUPLAZID=PA [e.g. AUVELITY, ZURZUVAE, NUPLAZID, bupropion]
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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsUnitedHealthcarePA 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
UnitedHealthcare commercial (Advantage 3-Tier). Anticonvulsants-seizures; many brand agents carry PA (APTIOM, KEPPRA, TOPAMAX, VIMPAT, XCOPRI); EPIDIOLEX PA+SP [e.g. APTIOM, BRIVIACT, DEPAKOTE, KEPPRA]
Submit to
UnitedHealthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsAetna (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. single ANTIDEPRESSANTS heading covers SSRI/SNRI/other; open generics, some brands ST [e.g. sertraline, escitalopram, fluoxetine, venlafaxine]
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
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsAetna (CVS Caremark)No PA
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 generics open; LAI injectables specialty PA [e.g. aripiprazole, quetiapine, risperidone, ABILIFY MAINTENA]
Submit to
Aetna (CVS Caremark) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsAetna (CVS Caremark)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
Aetna (CVS Caremark) commercial formulary. stimulants carry QL/PA (age/quantity edits) [e.g. amphetamine salts, methylphenidate, lisdexamfetamine (VYVANSE)]
Submit to
Aetna (CVS Caremark) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsAetna (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. antiseizure agents, open generics; some brands ST [e.g. levetiracetam, lamotrigine, topiramate, gabapentin]
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
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsAnthem Blue Cross (Elevance)No 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
Anthem Blue Cross (Elevance) commercial formulary. All anticonvulsant subclasses: QL only, no PA; open [e.g. levetiracetam, lamotrigine, carbamazepine er, divalproex]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsAnthem 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. Antipsychotics/antimanic subclasses carry PA + QL [e.g. aripiprazole, olanzapine, quetiapine, risperidone]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsCignaPA 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). ADHD stimulants broadly carry PA (incl generics) [e.g. methylphenidate, lisdexamfetamine, dextroamphetamine-amphetamine, AZSTARYS]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsCignaNo 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 commercial (Advantage 3-Tier). SSRIs open, QL only [e.g. fluoxetine, sertraline, escitalopram, paroxetine]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsCignaPA 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). generic AEDs open; branded (BRIVIACT/DILANTIN/OXTELLAR/XCOPRI/SPRITAM/TEGRETOL XR)=PA [e.g. gabapentin, lamotrigine, levetiracetam, topiramate]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesAetna (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. benzodiazepines, QL but open generics [e.g. alprazolam, lorazepam, clonazepam, diazepam]
Submit to
Aetna (CVS Caremark) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsAnthem 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. All ADHD agents (amphetamines, mixtures, alpha-agonists, SNRI) carry PA [e.g. amphetamine-dextroamphetamine, lisdexamfetamine, dextroamphetamine, atomoxetine]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesAnthem Blue Cross (Elevance)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
Anthem Blue Cross (Elevance) commercial formulary. Antianxiety + benzodiazepines: QL only, open [e.g. alprazolam, lorazepam, buspirone, diazepam]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).
ssri antidepressantsAnthem Blue Cross (Elevance)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
Anthem Blue Cross (Elevance) commercial formulary. SSRIs: no PA, open [e.g. citalopram, sertraline, fluoxetine, escitalopram]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsAnthem Blue Cross (Elevance)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
Anthem Blue Cross (Elevance) commercial formulary. Misc/serotonin modulators/TCA/MAOI/tetracyclic: QL only, open [e.g. bupropion, mirtazapine, nefazodone, amitriptyline]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesCignaNo 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 commercial (Advantage 3-Tier). benzodiazepines/buspirone open in anxiety section [e.g. alprazolam, lorazepam, buspirone]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = Part D patients (Medicare CY2023; infused agents read low).

commercial qhp

ssri antidepressantsMolina HealthcareNo PA
Switch?Switch usually clears — no PA
No prior authorization on this plan for this class — document the clinical reason for the change.
Document
Molina Healthcare commercial formulary. SSRI section open, QL only
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Sertraline3198KEscitalopram2725KFluoxetine1485KCitalopram1421KCitalopram Hbr1421KParoxetine720KDesvenlafaxine Succinate182KTrintellix101KVilazodone Hcl63KLexapro4KViibryd3KZoloft3KPaxil1KCelexa949Brisdelle0
# = Part D patients (Medicare CY2023; infused agents read low).
other antidepressantsMolina 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. vilazodone and Trintellix (vortioxetine) carry PA; bupropion open
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Trazodone3943KSertraline3198KEscitalopram2725KBupropion2219KMirtazapine1648KFluoxetine1485KVenlafaxine1161KAmitriptyline848KAmitriptyline Hcl848KBupropion Hcl734KDesvenlafaxine186KTrintellix101KNuplazid17KAuvelity16KSpravato6KWellbutrin Xl3KViibryd3KNefazodone1KZurzuvae34
# = Part D patients (Medicare CY2023; infused agents read low).
adhd stimulantsMolina 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. Several amphetamines and stimulants-misc carry PA; alpha-agonist ER PA
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Methylphenidate152KAtomoxetine66KGuanfacine47KLisdexamfetamine46KVyvanse41KDextroamphetamine15KDexmethylphenidate14KAdderall12KConcerta4KQelbree3KRitalin1KAzstarys1KAdzenys367Dyanavel367Strattera309Amphetamine213Zenzedi137
# = Part D patients (Medicare CY2023; infused agents read low).
anticonvulsantsMolina 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. 2 PA flags across anticonvulsants block
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Gabapentin7961KClonazepam1314KLevetiracetam841KTopiramate698KDivalproex692KLamotrigine671KCarbamazepine219KOxcarbazepine203KPhenytoin115KValproic Acid57KClobazam21KBriviact15KXcopri12KLyrica12KAptiom8KKeppra7KFycompa7KVimpat6KZtalmy12Brivaracetam Oral0
# = Part D patients (Medicare CY2023; infused agents read low).
atypical antipsychoticsMolina 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. paliperidone ER, aripiprazole ODT and others carry PA
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Quetiapine1485KAripiprazole649KOlanzapine605KRisperidone492KLurasidone118KVraylar118KInvega95KRexulti95KZiprasidone79KInvega Sustenna72KClozapine68KAbilify35KAbilify Maintena30KCaplyta27KAristada14KRisperdal9KRisperdal Consta8KLoxapine8KAbilify Asimtufii3KCobenfy1K
# = Part D patients (Medicare CY2023; infused agents read low).
anxiolytics benzodiazepinesMolina HealthcareNo PA
Switch?Switch usually clears — no PA
No prior authorization on this plan for this class — document the clinical reason for the change.
Document
Molina Healthcare commercial formulary. Antianxiety-misc and benzodiazepine sections open
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Alprazolam2313KLorazepam1880KZolpidem1559KBuspirone1554KClonazepam1314KDiazepam929KTemazepam374KTriazolam43KChlordiazepoxide26KXanax3KAtivan2KValium1KLoreev1KLunesta963Alprazolam Intensol187Halcion83
# = 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.