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WISeR pilot

Ohio Prior Authorization Requirements

Medicare TraditionalMedicaid MCOMedicare AdvantageMedicaid FFSCHIPDual-EligibleCommercial (employer / fully-insured)Ohio Single PBMPart DCommercial — Marketplace QHP

PA required

61%

1,135 verified rules

Verified Jun 8, 2026

Service category PA

All programs combined
Durable Medical Equipment
10/10Full PA
Physical Therapy
9/10Conditional
Specialty Drugs
9/10Conditional
pharmacy_standard
9/10Conditional
Home Health
9/10Conditional
Inpatient Hospital
9/10Conditional
Behavioral Health — Inpatient
9/10Conditional
Behavioral Health — Outpatient
9/10Conditional
Outpatient Surgery
9/10Conditional
advanced_imaging
9/10Conditional
Skilled Nursing Facility
8/10Conditional
long_term_care
8/10Conditional
dental
1/10Conditional
hospice
0/10No PA

Drug class PA

Part D federal protections flagged
Oral Oncology
17/18Conditional
ADHD Stimulants
16/18Conditional
growth_hormone
12/12Full PA
hepatitis_c_daa
12/12Full PA
tnf_inhibitors
12/12Full PA
hereditary_angioedema
12/12Full PA
pulmonary_arterial_hypertension
12/12Full PA
glp1_agonists
12/12Full PA
migraine_cgrp
12/12Full PA
asthma_copd_biologics
11/11Full PA
il_inhibitors_biologics
11/11Full PA
jak_inhibitors
11/11Full PA
ms_disease_modifying
11/11Full PA
testosterone_androgens
11/12Conditional
antifungals_systemic
11/12Conditional
atypical_antipsychotics
11/12Conditional
opioid_analgesics
10/12Conditional
pcsk9_inhibitors
10/12Conditional
anticonvulsants
10/12Conditional
ImmunosuppressantsFed. Protected
9/10Conditional
inhaled_respiratory
9/12Conditional
other_antidepressants
9/11Conditional
antiplatelets
8/12Conditional
HIV Antiretrovirals
7/18Conditional
Antipsychotics
7/8Conditional
Rare Disease / Orphan
7/8Conditional
ppi_acid_reducers
7/12Conditional
nsaids
7/11Conditional
Specialty Biologics
6/7Conditional
Brand (Generic Available)
6/7Conditional
Hepatitis C
6/7Conditional
Specialty Non-BiologicFed. Protected
6/7Conditional
Diabetes — Insulin
6/7Conditional
Brand (No Generic)
6/7Conditional
Diabetes — Non-Insulin
6/7Conditional
Controlled — Schedule II
6/7Conditional
opioid_use_disorder
6/12Conditional
Antidepressants
6/7Conditional
Controlled — Schedule III–V
6/7Conditional
Biosimilars
6/7Conditional
other_antidiabetics
6/12Conditional
hemophilia_factors
6/6Full PA
skeletal_muscle_relaxants
6/10Conditional
oral_retinoids
6/10Conditional
anxiolytics_benzodiazepines
6/11Conditional
sglt2_inhibitors
5/12Conditional
dpp4_inhibitors
5/12Conditional
overactive_bladder
5/12Conditional
cystic_fibrosis_modulators
5/5Full PA
insulins
5/12Conditional
anticoagulants_doac
4/12Conditional
statins
4/12Conditional
dermatology_biologics
4/4Full PA
sedative_hypnotics
4/11Conditional
wakefulness_agents
4/4Full PA
antihistamines
4/10Conditional
Opioid Treatment (MOUD)
3/5Conditional
ssri_antidepressants
3/10Conditional
oncology_supportive
3/3Full PA
oxybate_salts
3/3Full PA
vmat2_inhibitors
3/3Full PA
enzyme_replacement
3/3Full PA
arbs
3/10Conditional
calcium_channel_blockers
3/10Conditional
dalfampridine
3/3Full PA
immunoglobulins
3/3Full PA
triptans
2/11Conditional
bisphosphonates
2/11Conditional
hematopoietic_growth_factors
2/2Full PA
erectile_dysfunction
2/2Full PA
infertility_agents
2/2Full PA
weight_loss_agents
2/3Conditional
antiparkinson_agents
2/2Full PA
glp1_diabetes
1/1Full PA
snri_antidepressants
1/4Conditional
pulmonary_fibrosis
1/1Full PA
sleep_and_wakefulness_agents
1/1Full PA
osteoporosis_anabolics
1/1Full PA
respiratory_allergy_cough_cold
1/1Full PA
electrolytes_vitamins
1/1Full PA
metabolic_bone_other
1/1Full PA
antibacterials_systemic
1/1Full PA
sexual_dysfunction_agents
1/1Full PA
thyroid_agents
1/3Conditional
ophthalmic_dry_eye_misc
1/1Full PA
leukotriene_modifiers
1/10Conditional
antivirals_other
1/2Conditional
antiparasitics
1/1Full PA
immunological_immunomodulators
1/1Full PA
roflumilast
1/3Conditional
cns_miscellaneous
1/1Full PA
topical_steroids
1/5Conditional
gi_bowel_motility
1/1Full PA
ophthalmic_anti_inflammatory_anti_infective
1/1Full PA
other_cardiovascular
1/1Full PA
ophthalmic_agents
1/1Full PA
other_lipid_agents
1/1Full PA
allergen_immunotherapy
1/1Full PA
beta_blockers
1/10Conditional
continuous_glucose_monitors
1/1Full PA
diuretics
1/3Conditional
estrogens_hrt
1/1Full PA
ace_inhibitors
1/10Conditional
cough_cold
1/1Full PA
gi_other
1/1Full PA
antibiotics_general
1/1Full PA
gnrh_oncology_hormonal
1/1Full PA
transplant_immunosuppressants
1/1Full PA
miscellaneous_specialty
1/1Full PA
parkinsons_agents
1/1Full PA
cannabidiol
1/2Conditional
il1_other_immunomodulators
1/1Full PA
endometriosis_agents
1/1Full PA
immunomodulators
1/1Full PA
als_agents
1/1Full PA
myasthenia_gravis_agents
1/1Full PA
vasopressins
1/1Full PA
oncology_hormonal
1/2Conditional
calcium_receptor_agonists
1/1Full PA
polyneuropathy_agents
1/1Full PA
movement_disorders
1/1Full PA
carnitine_deficiency_agents
1/1Full PA
immunologic_misc
1/1Full PA
viscosupplements
1/1Full PA
multiple_sclerosis_agents
1/1Full PA
central_precocious_puberty
1/1Full PA
urea_cycle_disorder
1/1Full PA
chelating_agents
1/1Full PA
uterine_fibroids
1/1Full PA
fertility_regulators
1/1Full PA
paroxysmal_nocturnal_hemoglobinuria
1/1Full PA
pulmonary_fibrosis_agents
1/1Full PA
acromegaly_agents
1/1Full PA
growth_improvement_agents
1/1Full PA
sickle_cell_disease
1/1Full PA
narcolepsy_cataplexy_agents
1/1Full PA
cortisol_synthesis_inhibitors
1/1Full PA
autoimmune_physician_administered
1/1Full PA
bleeding_disorders_agents
1/1Full PA
botulinum_toxins
1/1Full PA
hereditary_tyrosinemia
1/1Full PA
platelet_disorders
1/1Full PA
ophthalmic_anti_vegf
1/2Conditional
calcium_regulators_misc
1/1Full PA
alpha1_antitrypsin_deficiency
1/1Full PA
dermatology_antipsoriatics
1/1Full PA
pde4_inhibitors_inflammatory
1/1Full PA
antibiotics_misc
1/1Full PA
cough_cold_allergy
1/1Full PA
dermatology_topical_other
1/1Full PA
il_inhibitors_ibd
1/1Full PA
hematopoietic_esa
1/1Full PA
calcimimetics
1/1Full PA
immunosuppressants_misc
1/1Full PA
neuro_psych_misc
1/1Full PA
hepatitis_b_agents
1/1Full PA
metabolic_disorder_agents
1/1Full PA
ophthalmic_anti_inflammatory
1/1Full PA
ovulation_stimulants
1/1Full PA
ssri_snri_other_antidepressants
1/1Full PA
cardiovascular_agents
1/1Full PA
dermatology_topical_and_biologics
1/1Full PA
diabetes_supplies_glucose_monitoring
1/1Full PA
hormone_replacement_contraceptives
1/1Full PA
opioid_partial_agonists
1/1Full PA
hepatitis_b
1/1Full PA
antilipemics_acl_inhibitors
1/1Full PA
migraine_misc
1/1Full PA
ibs_constipation
1/1Full PA
ibs_diarrhea
1/1Full PA
pancreatic_enzymes
1/1Full PA
dry_eye_disease
1/1Full PA
dermatology_atopic_dermatitis
1/1Full PA
nasal_agents
1/1Full PA
GLP-1 (Weight Loss)Fed. Protected
0/7No PA
Compounded MedicationsFed. Protected
0/7No PA
antidementia_alzheimers
0/1No PA
antimyasthenic_agents
0/1No PA
cannabinoid_antiemetics
0/2No PA
antigout_agents
0/1No PA
otic_agents
0/4No PA
bipolar_agents_lithium
0/1No PA
bph_agents
0/2No PA
anaphylaxis_epinephrine
0/1No PA
dental_oral_agents
0/1No PA
inflammatory_bowel_disease
0/2No PA
oral_corticosteroids
0/1No PA
antimycobacterials_tb
0/1No PA
vaccines
0/2No PA
contraceptives
0/3No PA
dental_products
0/1No PA
alzheimers_agents
0/2No PA
nutritional_dietary
0/1No PA
feminine_products
0/1No PA
hepatitis_b_antivirals
0/1No PA
smoking_cessation
0/1No PA
vitamins
0/2No PA
antilipemics_bile_acid_resins
0/1No PA
postherpetic_neuralgia
0/1No PA
antidiarrheals
0/1No PA
ophthalmic_antiglaucoma_beta_blockers
0/1No PA
mast_cell_stabilizers
0/1No PA
non_opioid_analgesics
0/2No PA
heart_failure_agents
0/1No PA
cns_misc
0/1No PA
ulcer_therapy_combinations
0/1No PA
ophthalmic_other
0/1No PA
antibacterials_misc
0/1No PA
antiarrhythmics
0/2No PA
vaginal_anti_infectives
0/2No PA
prenatal_vitamins
0/1No PA
cold_cough
0/1No PA
dermatology_scabicides_pediculicides
0/1No PA
rectal_corticosteroids
0/1No PA
ophthalmic_sympathomimetics
0/1No PA
dermatology_antiseborrheics
0/1No PA
salicylates
0/1No PA
nitrates
0/1No PA
anaphylaxis_treatment_agents
0/1No PA
dermatology_local_anesthetics
0/1No PA
aldosterone_antagonists
0/1No PA
genitourinary_misc
0/1No PA
electrolytes
0/1No PA
dermatology_misc
0/1No PA
anthelmintics
0/2No PA
alpha_blockers
0/1No PA
alcohol_deterrents
0/1No PA
musculoskeletal_therapy_agents
0/1No PA
nutritional_misc
0/1No PA
dermatology_rosacea
0/1No PA
antitubercular_agents
0/1No PA
antilipemics_cholesterol_absorption
0/1No PA
antiparkinsonian_agents
0/1No PA
psychotherapeutic_misc
0/1No PA
ophthalmic_antiglaucoma_combinations
0/1No PA
respiratory_misc
0/1No PA
antivirals_systemic
0/1No PA
antilipemics_fibrates
0/1No PA
smoking_deterrents
0/1No PA
glucocorticoids
0/1No PA
gi_antispasmodics
0/1No PA
ophthalmic_anti_infective_anti_inflammatory
0/1No PA
cephalosporins
0/1No PA
glucose_elevating_agents
0/1No PA
h2_receptor_antagonists
0/1No PA
ophthalmic_anti_infectives
0/1No PA
macrolides
0/1No PA
antilipemics_misc
0/1No PA
ophthalmic_anti_inflammatories
0/1No PA
xanthines
0/1No PA
fibromyalgia_agents
0/1No PA
allergenic_extracts
0/1No PA
dermatology_actinic_keratosis
0/1No PA
vitamin_d_analogs
0/1No PA
dermatology_wound_care
0/1No PA
laxatives
0/2No PA
ophthalmic_misc
0/1No PA
dermatology_antibiotics
0/1No PA
antimalarials
0/2No PA
antidementia_agents
0/1No PA
diabetic_supplies
0/1No PA
gi_anticholinergics
0/1No PA
ophthalmic_antiallergics
0/1No PA
mouth_throat_dental_agents
0/1No PA
fluoroquinolones
0/1No PA
ophthalmic_carbonic_anhydrase_inhibitors
0/1No PA
dermatology_acne
0/1No PA
tetracyclines
0/1No PA
digitalis_glycosides
0/1No PA
endocrine_metabolic_misc
0/1No PA
dmards
0/1No PA
dermatology_antipruritic
0/1No PA
cardiovascular_misc
0/1No PA
mood_stabilizers
0/1No PA
progestins
0/1No PA
benign_prostatic_hyperplasia
0/1No PA
gout_agents
0/2No PA
direct_renin_inhibitors
0/1No PA
phosphate_binders
0/1No PA
ophthalmic_rho_kinase_inhibitors
0/1No PA
anti_infectives_misc
0/1No PA
migraine_ergotamines
0/1No PA
menopausal_symptom_agents
0/1No PA
gastrointestinal_misc
0/1No PA
ophthalmic_prostaglandins
0/1No PA
dermatology_antifungals
0/1No PA
fibromyalgia_snri
0/1No PA
antianginal_nitrates
0/1No PA
antidiarrheal_probiotic
0/1No PA
antimycobacterial
0/1No PA
anticoagulants_warfarin
0/1No PA
opioid_reversal_antidotes
0/1No PA
other_antihyperlipidemics
0/1No PA
cardiotonics
0/1No PA
anticoagulants_heparins
0/1No PA
antiemetics
0/1No PA
vasopressin_desmopressin
0/1No PA
other_antihypertensives
0/1No PA
antimyasthenic_cholinergic
0/1No PA
arni_sacubitril
0/1No PA
hematinics_other
0/1No PA
migraine_other
0/1No PA
antipsoriatics_topical
0/1No PA
estrogens_progestins
0/1No PA
hemostatics
0/1No PA
topical_anti_infectives
0/1No PA
vaccines_toxoids
0/1No PA
corticosteroids_systemic
0/1No PA
digestive_enzymes
0/1No PA
serms
0/1No PA
interstitial_cystitis
0/1No PA
mouth_throat_dental
0/1No PA
medical_supplies_devices
0/1No PA
ophthalmic_glaucoma
0/2No PA
vasopressors_anaphylaxis
0/1No PA
anorectal_rectal
0/1No PA
pharmaceutical_adjuvants
0/1No PA
smoking_alcohol_deterrents
0/1No PA
vitamins_minerals
0/1No PA
nutritional_metabolic
0/1No PA
esketamine
0/1No PA
methadone
0/1No PA
antilipemics_omega3
0/1No PA
potassium_removing_agents
0/1No PA
gi_motility_ibs
0/1No PA

PA type breakdown

clinical_criteria
488
Full PA
135
Conditional
67
New starts only
8

Federal protected classes requiring PA

AntidepressantsPA required
AntipsychoticsPA required
Oral OncologyPA required
Oral OncologyPA required
ImmunosuppressantsPA required
AntipsychoticsPA required
AntidepressantsPA required
ImmunosuppressantsPA required

State flags

Medicaid expansion state
WISeR pilot (high data quality)
FFS-dominant (minimal MCO)

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