Auth57 · Specialty PA Pack
Oncology
For the oncology team on oral chemo and supportive care — prior auth and appeals, mapped nationwide.
Structured rules
907
PA-required
89%
Appeal layer
51/51
Criteria docs
51/51
The breadth · all 51 jurisdictions
Every state, quantified for oncology
| State | Approved · CY25 | Rules | PA-required | Appeal | Criteria docs |
|---|---|---|---|---|---|
| ● Recent · CY2025 disclosures — click a state to drill in | |||||
| WAWashington▸ viewing | 88.2% | 19 | 89% | ✓ | 13 |
| COColorado | 91.8% | 18 | 89% | ✓ | 2 |
| OHOhio | 77.7% | 21 | 95% | ✓ | 10 |
| All states · A–Z | |||||
| AKAlaska | — | 14 | 86% | ✓ | 6 |
| ALAlabama | — | 18 | 89% | ✓ | 1 |
| ARArkansas | — | 19 | 89% | ✓ | 7 |
| AZArizona | — | 19 | 89% | ✓ | 6 |
| CACalifornia | — | 25 | 88% | ✓ | 15 |
| CTConnecticut | — | 18 | 89% | ✓ | 1 |
| DCDistrict of Columbia | — | 18 | 89% | ✓ | 3 |
| DEDelaware | — | 18 | 89% | ✓ | 4 |
| FLFlorida | — | 19 | 89% | ✓ | 10 |
| GAGeorgia | — | 19 | 89% | ✓ | 17 |
| HIHawaii | — | 19 | 89% | ✓ | 14 |
| IAIowa | — | 18 | 89% | ✓ | 8 |
| IDIdaho | — | 15 | 87% | ✓ | 4 |
| ILIllinois | — | 18 | 89% | ✓ | 9 |
| INIndiana | — | 18 | 89% | ✓ | 8 |
| KSKansas | — | 18 | 89% | ✓ | 9 |
| KYKentucky | — | 19 | 89% | ✓ | 10 |
| LALouisiana | — | 17 | 88% | ✓ | 13 |
| MAMassachusetts | — | 17 | 88% | ✓ | 14 |
| MDMaryland | — | 17 | 88% | ✓ | 8 |
| MEMaine | — | 17 | 88% | ✓ | 4 |
| MIMichigan | — | 18 | 83% | ✓ | 7 |
| MNMinnesota | — | 15 | 87% | ✓ | 2 |
| MOMissouri | — | 20 | 90% | ✓ | 4 |
| MSMississippi | — | 19 | 89% | ✓ | 8 |
| MTMontana | — | 15 | 87% | ✓ | 1 |
| NCNorth Carolina | — | 19 | 89% | ✓ | 44 |
| NDNorth Dakota | — | 15 | 87% | ✓ | 3 |
| NENebraska | — | 18 | 89% | ✓ | 7 |
| NHNew Hampshire | — | 17 | 88% | ✓ | 2 |
| NJNew Jersey | — | 17 | 88% | ✓ | 5 |
| NMNew Mexico | — | 16 | 88% | ✓ | 2 |
| NVNevada | — | 17 | 88% | ✓ | 15 |
| NYNew York | — | 20 | 90% | ✓ | 14 |
| OKOklahoma | — | 20 | 90% | ✓ | 3 |
| OROregon | — | 19 | 89% | ✓ | 5 |
| PAPennsylvania | — | 17 | 88% | ✓ | 14 |
| RIRhode Island | — | 15 | 87% | ✓ | 2 |
| SCSouth Carolina | — | 18 | 89% | ✓ | 7 |
| SDSouth Dakota | — | 15 | 87% | ✓ | 1 |
| TNTennessee | — | 18 | 89% | ✓ | 9 |
| TXTexas | — | 21 | 86% | ✓ | 80 |
| UTUtah | — | 18 | 89% | ✓ | 5 |
| VAVirginia | — | 19 | 89% | ✓ | 6 |
| VTVermont | — | 14 | 86% | ✓ | 20 |
| WIWisconsin | — | 18 | 89% | ✓ | 10 |
| WVWest Virginia | — | 16 | 88% | ✓ | 4 |
| WYWyoming | — | 15 | 87% | ✓ | 1 |
Deep dive· Washington
Washington — oncology, 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, 2026Medicaid 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
Approved · CMS-0057-F 202588.2%across 4 payers (81.2–93.1%)
Draft · aggregatedSource ↗
- oncology oralPA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
commercial regulated
- oncology oral(UnitedHealthcare)PA requiredSwitch?PA required — switch supported by prior therapyThis 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.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Cigna)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Aetna (CVS Caremark))PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology supportive(Aetna (CVS Caremark))PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Ondansetron5206KLeucovorin28KProcrit25KDronabinol20KAranesp6KAprepitant5KEpogen4KNeulasta4KGranisetron4KGranix2KNeupogen1KLeukine89Emend15Mesna15Tecvayli13new ’22Elrexfio0new ’23Epkinly0new ’23Talvey0new ’23# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Anthem Blue Cross (Elevance))PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA + specialty pharmacy. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
dual eligible
- oncology oralPA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
medicaid ffs
Approved · CMS-0057-F 202554.8%
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.
- oncology oralPA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
medicare advantage
- oncology oralPA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
medicare traditional
- oncology oralNo PASwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
part d
- oncology oralNo PASwitch?Switch usually clears — no PANo prior authorization on this plan for this class — document the clinical reason for the change.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Centene)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Unitedhealthcare)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Humana)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Cigna)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Aetna)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology oral(Kaiser)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
commercial qhp
- oncology oral(Molina Healthcare)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Abiraterone55KXtandi35KVenclexta26KIbrance16KImatinib16KImbruvica15KCalquence15KTagrisso12KVerzenio11KLynparza7KAlecensa2KCapecitabine50Temozolomide21# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
- oncology supportive(Molina Healthcare)PA requiredSwitch?PA required — switch supported by prior therapyThis plan requires PA. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.Brands···Ondansetron5206KLeucovorin28KProcrit25KDronabinol20KAranesp6KAprepitant5KEpogen4KNeulasta4KGranisetron4KGranix2KNeupogen1KLeukine89Emend15Mesna15Tecvayli13new ’22Elrexfio0new ’23Epkinly0new ’23Talvey0new ’23# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
If denied in Washington
📨 Office of Administrative Hearings (OAH)
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Full criteria, sources & appeal paths — all 51 states.
You’ve seen the breadth and one state in full. The complete Oncologypack — 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.