Auth57 · Specialty PA Pack

Rheumatology

For the rheumatologist whose patients live on biologics — every plan's PA rule and the appeal path, across all 51 states.

Unlock all 51 states →See a free state →

Structured rules

1,426

PA-required

98%

Appeal layer

51/51

Criteria docs

43/51

The breadth · all 51 jurisdictions

Every state, quantified for rheumatology

State	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	32	100%	✓	4
COColorado	91.8%	29	90%	✓	8
OHOhio	77.7%	34	100%	✓	14
All states · A–Z
AKAlaska	—	19	100%	✓	3
ALAlabama	—	31	100%	✓	6
ARArkansas	—	32	100%	✓	3
AZArizona	—	29	100%	✓	3
CACalifornia	—	34	91%	✓	8
CTConnecticut	—	30	100%	✓	2
DCDistrict of Columbia	—	30	90%	✓	3
DEDelaware	—	28	100%	✓	3
FLFlorida	—	31	100%	✓	—
GAGeorgia	—	33	91%	✓	2
HIHawaii	—	31	84%	✓	3
IAIowa	—	28	100%	✓	7
IDIdaho	—	22	100%	✓	3
ILIllinois	—	29	100%	✓	3
INIndiana	—	28	100%	✓	1
KSKansas	—	30	100%	✓	38
KYKentucky	—	33	100%	✓	3
LALouisiana	—	27	100%	✓	6
MAMassachusetts	—	25	100%	✓	3
MDMaryland	—	26	88%	✓	2
MEMaine	—	26	100%	✓	2
MIMichigan	—	28	100%	✓	5
MNMinnesota	—	22	100%	✓	1
MOMissouri	—	36	100%	✓	—
MSMississippi	—	33	100%	✓	4
MTMontana	—	20	100%	✓	1
NCNorth Carolina	—	33	100%	✓	1
NDNorth Dakota	—	21	100%	✓	—
NENebraska	—	26	100%	✓	4
NHNew Hampshire	—	26	100%	✓	—
NJNew Jersey	—	27	100%	✓	3
NMNew Mexico	—	22	100%	✓	—
NVNevada	—	26	100%	✓	10
NYNew York	—	31	100%	✓	12
OKOklahoma	—	34	100%	✓	2
OROregon	—	31	90%	✓	2
PAPennsylvania	—	28	100%	✓	9
RIRhode Island	—	20	100%	✓	—
SCSouth Carolina	—	29	100%	✓	4
SDSouth Dakota	—	19	100%	✓	—
TNTennessee	—	30	100%	✓	3
TXTexas	—	34	100%	✓	28
UTUtah	—	31	100%	✓	24
VAVirginia	—	32	91%	✓	3
VTVermont	—	18	100%	✓	5
WIWisconsin	—	29	100%	✓	1
WVWest Virginia	—	24	100%	✓	—
WYWyoming	—	19	100%	✓	3

Deep dive· Washington

Washington — rheumatology, 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 ↗

medicaid ffs

Approved · CMS-0057-F 202554.8%

jak inhibitorsPA 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.

commercial regulated

tnf inhibitors(UnitedHealthcare)PA required
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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(UnitedHealthcare)PA required
Switch?PA + step therapy — a prior in-class trial usually clears it
This plan gates the class with PA + quantity limit + specialty pharmacy + 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(UnitedHealthcare)PA required
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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Cigna)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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(Cigna)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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(Cigna)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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Aetna (CVS Caremark))PA required
Switch?PA + step therapy — a prior in-class trial usually clears it
This plan gates the class with PA + specialty pharmacy + 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(Anthem Blue Cross (Elevance))PA required
Switch?PA + step therapy — a prior in-class trial usually clears it
This plan gates the class with PA + specialty pharmacy + 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Anthem 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(Anthem 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.

part d

jak inhibitors(Centene)PA 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Centene)PA 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(Centene)PA 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(Unitedhealthcare)PA 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(Unitedhealthcare)PA 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Unitedhealthcare)PA 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(Humana)PA 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(Humana)PA 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Humana)PA 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Cigna)PA 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(Cigna)PA 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(Cigna)PA 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Aetna)PA 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(Aetna)PA 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(Aetna)PA 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(Kaiser)PA 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Kaiser)PA 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
il inhibitors biologics(Kaiser)PA 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.

commercial qhp

il inhibitors biologics(Molina Healthcare)PA 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.
Brands
···
Dupixent88KEnbrel53KSkyrizi37KOtezla31KCosentyx28KStelara25KTaltz14KTremfya11KBimzelx1Knew ’23Ilumya696Infliximab337Omvoh130new ’23Actimmune47Pyzchiva0new ’24Selarsdi0new ’24Ustekinumab0
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
tnf inhibitors(Molina Healthcare)PA 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.
Brands
···
Humira90KDupixent88KEnbrel53KSkyrizi37KOtezla31KRinvoq29KStelara25KXeljanz19KTaltz14KCimzia7KSimponi5KAmjevita5KInflectra1KCyltezo1KHadlima1KAvsola486Infliximab337Simlandi145new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.
jak inhibitors(Molina Healthcare)PA 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.
Brands
···
Rinvoq29KXeljanz19KOpzelura19Knew ’21Sotyktu2Knew ’22Olumiant2KCibinqo536new ’22Litfulo274new ’23Leqselvi0new ’24
# = Part D patients (Medicare CY2023; infused agents read low). new = FDA-approved 2021+.

If denied in Washington

📨 Office of Administrative Hearings (OAH)

Unlock the full pack

Full criteria, sources & appeal paths — all 51 states.

You’ve seen the breadth and one state in full. The complete Rheumatologypack — 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.