Auth57 · Specialty PA Pack
Pulmonology
For the pulmonologist managing inhalers, biologics, and PAH — the PA and appeal map, all 51 states.
Structured rules
1,954
PA-required
70%
Appeal layer
51/51
Criteria docs
50/51
The breadth · all 51 jurisdictions
Every state, quantified for pulmonology
| State | Rules | PA-required | Appeal | Criteria docs |
|---|---|---|---|---|
| AKAlaska | 25 | 68% | ✓ | 6 |
| ALAlabama | 40 | 70% | ✓ | 8 |
| ARArkansas | 46 | 72% | ✓ | 6 |
| AZArizona | 42 | 71% | ✓ | 5 |
| CACalifornia | 45 | 69% | ✓ | 6 |
| COColorado | 41 | 71% | ✓ | 7 |
| CTConnecticut | 40 | 70% | ✓ | 4 |
| DCDistrict of Columbia | 40 | 70% | ✓ | 9 |
| DEDelaware | 40 | 73% | ✓ | 4 |
| FLFlorida | 41 | 71% | ✓ | 2 |
| GAGeorgia | 46 | 67% | ✓ | 15 |
| HIHawaii | 42 | 71% | ✓ | 7 |
| IAIowa | 40 | 70% | ✓ | 7 |
| IDIdaho | 29 | 69% | ✓ | 8 |
| ILIllinois | 41 | 71% | ✓ | 1 |
| INIndiana | 40 | 73% | ✓ | 6 |
| KSKansas | 40 | 70% | ✓ | 9 |
| KYKentucky | 44 | 70% | ✓ | 4 |
| LALouisiana | 36 | 69% | ✓ | 12 |
| MAMassachusetts | 34 | 71% | ✓ | 6 |
| MDMaryland | 36 | 69% | ✓ | 8 |
| MEMaine | 37 | 70% | ✓ | 5 |
| MIMichigan | 37 | 73% | ✓ | 16 |
| MNMinnesota | 30 | 70% | ✓ | 2 |
| MOMissouri | 46 | 70% | ✓ | 6 |
| MSMississippi | 43 | 70% | ✓ | 8 |
| MTMontana | 29 | 69% | ✓ | 3 |
| NCNorth Carolina | 46 | 74% | ✓ | 23 |
| NDNorth Dakota | 28 | 64% | ✓ | 3 |
| NENebraska | 38 | 71% | ✓ | 4 |
| NHNew Hampshire | 37 | 70% | ✓ | — |
| NJNew Jersey | 38 | 66% | ✓ | 4 |
| NMNew Mexico | 30 | 67% | ✓ | 3 |
| NVNevada | 36 | 69% | ✓ | 19 |
| NYNew York | 42 | 71% | ✓ | 9 |
| OHOhio | 45 | 73% | ✓ | 14 |
| OKOklahoma | 45 | 69% | ✓ | 3 |
| OROregon | 44 | 73% | ✓ | 4 |
| PAPennsylvania | 37 | 70% | ✓ | 12 |
| RIRhode Island | 29 | 69% | ✓ | 1 |
| SCSouth Carolina | 40 | 73% | ✓ | 8 |
| SDSouth Dakota | 26 | 65% | ✓ | 4 |
| TNTennessee | 41 | 71% | ✓ | 1 |
| TXTexas | 45 | 71% | ✓ | 48 |
| UTUtah | 42 | 71% | ✓ | 11 |
| VAVirginia | 44 | 70% | ✓ | 6 |
| VTVermont | 25 | 68% | ✓ | 13 |
| WAWashington | 45 | 71% | ✓ | 8 |
| WIWisconsin | 40 | 73% | ✓ | 2 |
| WVWest Virginia | 33 | 73% | ✓ | 2 |
| WYWyoming | 28 | 68% | ✓ | 8 |
Free preview· Texas
What a fully-unlocked state looks like
medicaid ffs
- asthma copd biologicsPA requiredTX Medicaid PDL: non-preferred agents require PA (step therapy). Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
- inhaled respiratoryPA requiredTX Medicaid PDL: non-preferred agents require PA (step therapy). Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
- pulmonary arterial hypertensionPA requiredTX Medicaid PDL: non-preferred agents require PA (step therapy). Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
commercial regulated
- pulmonary arterial hypertension(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). Respiratory-pulmonary hypertension; all carry PA+QL+SP (TYVASO PA+SP) [e.g. ADEMPAS, OPSUMIT, TYVASO, TADLIQ]
- leukotriene modifiers(UnitedHealthcare)No PAUnitedHealthcare commercial (Advantage 3-Tier). Leukotriene modifier subset within asthma/COPD heading; tier 1-2, QL/none, no PA [e.g. montelukast, zafirlukast]
- asthma copd biologics(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). Asthma/COPD biologic subset within asthma/COPD heading; all carry PA+QL+SP [e.g. FASENRA, NUCALA, TEZSPIRE, XOLAIR]
- inhaled respiratory(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). Respiratory-asthma and COPD; inhalers QL/RS, but biologics in this heading (FASENRA, NUCALA, TEZSPIRE, XOLAIR PA+QL+SP) and YUPELRI carry PA [e.g. albuterol, BREO ELLIPTA, SYMBICORT, TRELEGY ELLIPTA]
- inhaled respiratory(Cigna)No PACigna commercial (Advantage 3-Tier). inhalers/montelukast largely open (QL); BRONCHITOL=PA outlier [e.g. albuterol, ADVAIR HFA, BREO ELLIPTA, SPIRIVA RESPIMAT]
- asthma copd biologics(Cigna)PA requiredCigna commercial (Advantage 3-Tier). respiratory biologics carry SP+PA [e.g. FASENRA PEN, NUCALA, TEZSPIRE, XOLAIR]
- pulmonary arterial hypertension(Cigna)PA requiredCigna commercial (Advantage 3-Tier). PAH agents in respiratory section, SP+PA [e.g. ADEMPAS, OPSUMIT, TRACLEER, TYVASO]
- leukotriene modifiers(Aetna (CVS Caremark))No PAAetna (CVS Caremark) commercial formulary. leukotriene receptor antagonists, open generics [e.g. montelukast, zafirlukast, zileuton]
- pulmonary arterial hypertension(Aetna (CVS Caremark))PA requiredAetna (CVS Caremark) commercial formulary. specialty PAH, PA standard [e.g. sildenafil (PAH), tadalafil (PAH), ambrisentan, bosentan]
- inhaled respiratory(Aetna (CVS Caremark))No PAAetna (CVS Caremark) commercial formulary. anticholinergic/beta-agonist/steroid inhalers (SABA/LABA/ICS/LAMA combos), brand-dominant; ST/preferred-product [e.g. albuterol, budesonide-formoterol, tiotropium, fluticasone]
- asthma copd biologics(Aetna (CVS Caremark))PA requiredAetna (CVS Caremark) commercial formulary. severe asthma biologics, specialty PA [e.g. omalizumab (XOLAIR), mepolizumab (NUCALA), benralizumab (FASENRA), dupilumab]
- leukotriene modifiers(Anthem Blue Cross (Elevance))No PAAnthem Blue Cross (Elevance) commercial formulary. Leukotriene receptor antagonists: QL only, open [e.g. montelukast, zafirlukast]
- pulmonary arterial hypertension(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Prostaglandin vasodilators, endothelin receptor antagonists, PDE5, sGC stimulators: PA + SP [e.g. treprostinil, ambrisentan, tadalafil (ALYQ), ADEMPAS riociguat]
- inhaled respiratory(Anthem Blue Cross (Elevance))No PAAnthem Blue Cross (Elevance) commercial formulary. Beta-adrenergics, inhaled steroids, anticholinergics, adrenergic combos: QL only, open [e.g. albuterol, budesonide-formoterol, ipratropium, mometasone inhaler]
part d
- pulmonary arterial hypertension(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- inhaled respiratory(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- leukotriene modifiers(Centene)No PACentene Part D (CMS formulary file, plan-grounded).
- asthma copd biologics(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- inhaled respiratory(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- asthma copd biologics(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- leukotriene modifiers(Unitedhealthcare)No PAUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- pulmonary arterial hypertension(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- inhaled respiratory(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- asthma copd biologics(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- pulmonary arterial hypertension(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- leukotriene modifiers(Humana)No PAHumana Part D (CMS formulary file, plan-grounded).
- inhaled respiratory(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- pulmonary arterial hypertension(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- leukotriene modifiers(Cigna)No PACigna Part D (CMS formulary file, plan-grounded).
- asthma copd biologics(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- asthma copd biologics(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- inhaled respiratory(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- pulmonary arterial hypertension(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- leukotriene modifiers(Aetna)No PAAetna Part D (CMS formulary file, plan-grounded).
commercial qhp
- pulmonary arterial hypertension(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- inhaled respiratory(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- asthma copd biologics(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- leukotriene modifiers(Marketplace QHP (aggregate))No PAACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- inhaled respiratory(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Beta-adrenergic inhalers carry 2 ST; steroid inhalants and combos open
- asthma copd biologics(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Anti-IgE and IL-5 antagonist respiratory biologics carry PA
- pulmonary arterial hypertension(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Prostaglandin vasodilators / PAH agents carry 14 PA
- leukotriene modifiers(Molina Healthcare)No PAMolina Healthcare commercial formulary. montelukast/zafirlukast QL only, no PA/ST
If denied in Texas
📨 Program Support Unit (PSU)
Unlock the full pack
Full criteria, sources & appeal paths — all 51 states.
You’ve seen the breadth and one state in full. The complete Pulmonologypack — 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.