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WA
WISeR pilot

Washington Prior Authorization Requirements

Medicaid MCO • Apple HealthMedicare TraditionalMedicare AdvantagePart DMedicaid FFS • Apple HealthDual-EligibleCommercial (employer / fully-insured)

PA required

71%

275 verified rules

Verified May 23, 2026

Service category PA

All programs combined
Specialty Drugs
9/10Conditional
Durable Medical Equipment
9/10Conditional
Inpatient Hospital
8/10Conditional
Skilled Nursing Facility
8/10Conditional
Home Health
8/10Conditional
Mental Health — Inpatient
8/10Conditional
Outpatient Surgery
8/10Conditional
Occupational Therapy
7/10Conditional
Substance Use Treatment
7/10Conditional
Ambulance Transport
7/10Conditional
Diagnostic Imaging
7/10Conditional
Physical Therapy
7/10Conditional
Speech Therapy
7/10Conditional
advanced_imaging
7/10Conditional
Laboratory
0/10No PA

Drug class PA

Part D federal protections flagged
Rare Disease / Orphan
6/7Conditional
Immunosuppressants
6/8Conditional
Antipsychotics
5/7Conditional
Brand (No Generic)
5/6Conditional
Biosimilars
5/6Conditional
Specialty Non-Biologic
5/6Conditional
Controlled — Schedule III–V
5/6Conditional
ADHD Stimulants
5/6Conditional
Diabetes — Insulin
5/6Conditional
Diabetes — Non-Insulin
5/6Conditional
Specialty Biologics
5/6Conditional
Controlled — Schedule II
5/6Conditional
Brand (Generic Available)
5/6Conditional
Hepatitis C
5/6Conditional
HIV Antiretrovirals
4/6Conditional
Antidepressants
4/6Conditional
Oral Oncology
4/6Conditional
GLP-1 (Weight Loss)
2/6Conditional
glp1_diabetes
1/1Full PA
Opioid Treatment (MOUD)
0/6No PA
Compounded Medications
0/6No PA

PA type breakdown

Conditional
116
Full PA
74
clinical_criteria
4

Federal protected classes requiring PA

AntidepressantsPA required
HIV AntiretroviralsPA required
HIV AntiretroviralsPA required
AntipsychoticsPA required
ImmunosuppressantsPA required
Oral OncologyPA required
AntidepressantsPA required
ImmunosuppressantsPA required
Oral OncologyPA required
AntipsychoticsPA required

State flags

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

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