Auth57 · Specialty PA Pack

Pulmonology

For the pulmonologist managing inhalers, biologics, and PAH — the PA and appeal map, all 51 states.

See a free state →Unlock 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	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	45	71%	✓	8
COColorado	91.8%	41	71%	✓	7
OHOhio	77.7%	45	73%	✓	14
All states · A–Z
AKAlaska	—	25	68%	✓	6
ALAlabama	—	40	70%	✓	8
ARArkansas	—	46	72%	✓	6
AZArizona	—	42	71%	✓	5
CACalifornia	—	45	69%	✓	6
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
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
WIWisconsin	—	40	73%	✓	2
WVWest Virginia	—	33	73%	✓	2
WYWyoming	—	28	68%	✓	8

Deep dive· Washington

Washington — pulmonology, 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%

asthma copd biologicsPA 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
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryPA 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
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionPA 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
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).

commercial regulated

pulmonary arterial hypertensionUnitedHealthcarePA 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). Respiratory-pulmonary hypertension; all carry PA+QL+SP (TYVASO PA+SP) [e.g. ADEMPAS, OPSUMIT, TYVASO, TADLIQ]
Submit to
UnitedHealthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryUnitedHealthcarePA 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). 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]
Submit to
UnitedHealthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsUnitedHealthcarePA 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). Asthma/COPD biologic subset within asthma/COPD heading; all carry PA+QL+SP [e.g. FASENRA, NUCALA, TEZSPIRE, XOLAIR]
Submit to
UnitedHealthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersUnitedHealthcareNo PA
Switch?PA required — switch supported by prior therapy
This plan requires PA + quantity limit. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
Document
UnitedHealthcare commercial (Advantage 3-Tier). Leukotriene modifier subset within asthma/COPD heading; tier 1-2, QL/none, no PA [e.g. montelukast, zafirlukast]
Submit to
UnitedHealthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryCignaNo 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
Cigna commercial (Advantage 3-Tier). inhalers/montelukast largely open (QL); BRONCHITOL=PA outlier [e.g. albuterol, ADVAIR HFA, BREO ELLIPTA, SPIRIVA RESPIMAT]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsCignaPA 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). respiratory biologics carry SP+PA [e.g. FASENRA PEN, NUCALA, TEZSPIRE, XOLAIR]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionCignaPA 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). PAH agents in respiratory section, SP+PA [e.g. ADEMPAS, OPSUMIT, TRACLEER, TYVASO]
Submit to
Cigna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionAetna (CVS Caremark)PA required
Switch?PA required — switch supported by prior therapy
This plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
Document
Aetna (CVS Caremark) commercial formulary. specialty PAH, PA standard [e.g. sildenafil (PAH), tadalafil (PAH), ambrisentan, bosentan]
Submit to
Aetna (CVS Caremark) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsAetna (CVS Caremark)PA required
Switch?PA required — switch supported by prior therapy
This plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
Document
Aetna (CVS Caremark) commercial formulary. severe asthma biologics, specialty PA [e.g. omalizumab (XOLAIR), mepolizumab (NUCALA), benralizumab (FASENRA), dupilumab]
Submit to
Aetna (CVS Caremark) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryAetna (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. anticholinergic/beta-agonist/steroid inhalers (SABA/LABA/ICS/LAMA combos), brand-dominant; ST/preferred-product [e.g. albuterol, budesonide-formoterol, tiotropium, fluticasone]
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
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionAnthem 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. Prostaglandin vasodilators, endothelin receptor antagonists, PDE5, sGC stimulators: PA + SP [e.g. treprostinil, ambrisentan, tadalafil (ALYQ), ADEMPAS riociguat]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryAnthem 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. Beta-adrenergics, inhaled steroids, anticholinergics, adrenergic combos: QL only, open [e.g. albuterol, budesonide-formoterol, ipratropium, mometasone inhaler]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersAnthem 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. Leukotriene receptor antagonists: QL only, open [e.g. montelukast, zafirlukast]
Submit to
Anthem Blue Cross (Elevance) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersAetna (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. leukotriene receptor antagonists, open generics [e.g. montelukast, zafirlukast, zileuton]
Submit to
Aetna (CVS Caremark) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).

part d

pulmonary arterial hypertensionCentenePA 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
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryCentenePA 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
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsCentenePA 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
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionUnitedhealthcarePA 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
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryUnitedhealthcarePA 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
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsUnitedhealthcarePA 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
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryHumanaPA 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
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsHumanaPA 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
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionHumanaPA 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
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionCignaPA 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
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsCignaPA 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
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryCignaPA 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
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsAetnaPA 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
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryAetnaPA 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
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionAetnaPA 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
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionKaiserPA 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
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsKaiserPA 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
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryKaiserPA 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
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersCenteneNo 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
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersUnitedhealthcareNo 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
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersHumanaNo 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
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersCignaNo 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
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersAetnaNo PA
Switch?Switch usually clears — no PA
No prior authorization on this plan for this class — document the clinical reason for the change.
Document
Aetna Part D (CMS formulary file, plan-grounded).
Submit to
Aetna · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).
leukotriene modifiersKaiserNo 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
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).

commercial qhp

leukotriene modifiersMolina HealthcareNo PA▲ Most difficult
Switch?PA + step therapy — a prior in-class trial usually clears it
This plan gates the class with PA + quantity limit + step therapy. A documented trial (or failure/intolerance) of an in-class agent — which your patient already has — typically satisfies the step requirement, so the switch clears.
Document
Molina Healthcare commercial formulary. montelukast/zafirlukast QL only, no PA/ST
Step therapy
Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Montelukast3176KZafirlukast16KSingulair3KZileuton2KZyflo113
# = Part D patients (Medicare CY2023; infused agents read low).
inhaled respiratoryMolina HealthcarePA 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
Molina Healthcare commercial formulary. Beta-adrenergic inhalers carry 2 ST; steroid inhalants and combos open
Step therapy
Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Albuterol6818KFluticasone5289KMontelukast3176KTrelegy1268KTrelegy Ellipta1268KIpratropium865KVentolin850KBreo596KBreo Ellipta596KSymbicort588KMometasone522KSpiriva485KWixela447KSpiriva Respimat327KAdvair310KAnoro Ellipta291KBreyna211KArnuity Ellipta182KTiotropium66KTezspire6K
# = Part D patients (Medicare CY2023; infused agents read low).
asthma copd biologicsMolina 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. Anti-IgE and IL-5 antagonist respiratory biologics carry PA
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
# = Part D patients (Medicare CY2023; infused agents read low).
pulmonary arterial hypertensionMolina 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. Prostaglandin vasodilators / PAH agents carry 14 PA
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Sildenafil240KTadalafil88KOpsumit11KAmbrisentan7KAdempas6KTyvaso4KUptravi4KOrenitram2KBosentan635Alyq182Remodulin110Tracleer107Treprostinil24Tadliq14Selexipag0
# = 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.