Auth57 · Specialty PA Pack
Gastroenterology
For the GI practice running IBD biologics and Hep C therapy — what needs prior auth, and how to win the appeal.
Structured rules
1,955
PA-required
99%
Appeal layer
51/51
Criteria docs
47/51
The breadth · all 51 jurisdictions
Every state, quantified for gastroenterology
| State | Rules | PA-required | Appeal | Criteria docs |
|---|---|---|---|---|
| AKAlaska | 26 | 100% | ✓ | 3 |
| ALAlabama | 42 | 100% | ✓ | 4 |
| ARArkansas | 44 | 100% | ✓ | 5 |
| AZArizona | 40 | 100% | ✓ | 2 |
| CACalifornia | 46 | 91% | ✓ | 7 |
| COColorado | 40 | 93% | ✓ | 11 |
| CTConnecticut | 41 | 100% | ✓ | 4 |
| DCDistrict of Columbia | 41 | 93% | ✓ | 4 |
| DEDelaware | 39 | 100% | ✓ | 4 |
| FLFlorida | 42 | 100% | ✓ | 2 |
| GAGeorgia | 45 | 93% | ✓ | 11 |
| HIHawaii | 42 | 88% | ✓ | 5 |
| IAIowa | 39 | 100% | ✓ | 7 |
| IDIdaho | 30 | 100% | ✓ | 2 |
| ILIllinois | 40 | 100% | ✓ | 3 |
| INIndiana | 39 | 100% | ✓ | 3 |
| KSKansas | 41 | 100% | ✓ | 18 |
| KYKentucky | 45 | 100% | ✓ | 5 |
| LALouisiana | 37 | 100% | ✓ | 8 |
| MAMassachusetts | 34 | 100% | ✓ | 1 |
| MDMaryland | 36 | 92% | ✓ | 6 |
| MEMaine | 36 | 100% | ✓ | 4 |
| MIMichigan | 38 | 97% | ✓ | 13 |
| MNMinnesota | 30 | 100% | ✓ | 4 |
| MOMissouri | 49 | 100% | ✓ | 3 |
| MSMississippi | 45 | 100% | ✓ | 10 |
| MTMontana | 28 | 100% | ✓ | 2 |
| NCNorth Carolina | 45 | 100% | ✓ | 16 |
| NDNorth Dakota | 29 | 100% | ✓ | 1 |
| NENebraska | 36 | 100% | ✓ | 2 |
| NHNew Hampshire | 36 | 100% | ✓ | — |
| NJNew Jersey | 37 | 100% | ✓ | 2 |
| NMNew Mexico | 30 | 100% | ✓ | — |
| NVNevada | 36 | 100% | ✓ | 11 |
| NYNew York | 42 | 100% | ✓ | 12 |
| OHOhio | 46 | 100% | ✓ | 12 |
| OKOklahoma | 46 | 100% | ✓ | 2 |
| OROregon | 43 | 93% | ✓ | 3 |
| PAPennsylvania | 38 | 100% | ✓ | 14 |
| RIRhode Island | 28 | 100% | ✓ | 1 |
| SCSouth Carolina | 40 | 100% | ✓ | 6 |
| SDSouth Dakota | 26 | 100% | ✓ | — |
| TNTennessee | 41 | 100% | ✓ | 3 |
| TXTexas | 46 | 100% | ✓ | 73 |
| UTUtah | 42 | 100% | ✓ | 16 |
| VAVirginia | 44 | 93% | ✓ | 4 |
| VTVermont | 25 | 100% | ✓ | 1 |
| WAWashington | 44 | 100% | ✓ | 9 |
| WIWisconsin | 40 | 100% | ✓ | 2 |
| WVWest Virginia | 33 | 100% | ✓ | — |
| WYWyoming | 27 | 100% | ✓ | 5 |
Free preview· Texas
What a fully-unlocked state looks like
medicaid ffs
- hepatitis c daaPA requiredTX Medicaid PDL: non-preferred agents require PA (step therapy). Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
- tnf inhibitorsPA requiredTX Medicaid PDL: non-preferred agents require PA (step therapy). Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
- il inhibitors biologicsPA requiredTX Medicaid PDL: non-preferred agents require PA (step therapy). Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
- jak inhibitorsPA requiredTX Medicaid PDL: non-preferred agents require PA (step therapy). Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
commercial regulated
- tnf inhibitors(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). TNF inhibitor subset within Immunological heading; all carry PA+QL+SP [e.g. HUMIRA, ENBREL, CIMZIA, SIMPONI]
- il inhibitors biologics(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). IL inhibitor subset within Immunological heading; all carry PA+QL+SP (some +ST) [e.g. COSENTYX, SKYRIZI, BIMZELX, OMVOH]
- jak inhibitors(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). JAK inhibitor subset within Immunological heading; all carry PA+QL+SP [e.g. RINVOQ, XELJANZ, XELJANZ XR, OLUMIANT]
- hepatitis c daa(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). Hep C DAAs within Antivirals heading; all carry PA+QL+SP (HARVONI/LEDIPASVIR-SOFOSBUVIR add ST) [e.g. EPCLUSA, HARVONI, MAVYRET, VOSEVI]
- hepatitis c daa(Cigna)PA requiredCigna commercial (Advantage 3-Tier). HCV direct-acting antivirals SP+PA [e.g. EPCLUSA, HARVONI, VOSEVI, ZEPATIER]
- tnf inhibitors(Cigna)PA requiredCigna commercial (Advantage 3-Tier). TNF inhibitors SP+PA in pain/inflammatory section [e.g. HUMIRA, ENBREL, INFLECTRA, CIMZIA]
- il inhibitors biologics(Cigna)PA requiredCigna commercial (Advantage 3-Tier). IL-17/23/etc biologics SP+PA [e.g. COSENTYX, TALTZ, SKYRIZI, TREMFYA]
- jak inhibitors(Cigna)PA requiredCigna commercial (Advantage 3-Tier). JAK/TYK2 inhibitors SP+PA [e.g. RINVOQ, XELJANZ, OLUMIANT, SOTYKTU]
- hepatitis c daa(Aetna (CVS Caremark))PA requiredAetna (CVS Caremark) commercial formulary. HCV DAAs, specialty, PA standard [e.g. MAVYRET, EPCLUSA, sofosbuvir-velpatasvir, ZEPATIER]
- tnf inhibitors(Aetna (CVS Caremark))PA requiredAetna (CVS Caremark) commercial formulary. self-administered autoimmune biologics + JAK (TNF/IL/JAK), specialty PSP, PA/ST [e.g. HUMIRA, ENBREL, DUPIXENT, SKYRIZI]
- tnf inhibitors(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Soluble TNF receptor + anti-TNF monoclonals: PA/SP [e.g. ENBREL, HUMIRA, etanercept, adalimumab]
- il inhibitors biologics(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Interleukin antagonists + costimulation modulators: PA/SP (some ST) [e.g. STELARA, SKYRIZI, ustekinumab, ORENCIA abatacept]
- hepatitis c daa(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Hepatitis C agents + combinations: PA + SP [e.g. EPCLUSA sofosbuvir-velpatasvir, PEGASYS peginterferon]
- jak inhibitors(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Antirheumatic JAK + oncology JAK: PA/SP [e.g. RINVOQ, XELJANZ, upadacitinib, JAKAFI ruxolitinib]
part d
- il inhibitors biologics(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- tnf inhibitors(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- jak inhibitors(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- jak inhibitors(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- tnf inhibitors(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- il inhibitors biologics(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- tnf inhibitors(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- jak inhibitors(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- il inhibitors biologics(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- tnf inhibitors(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- jak inhibitors(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- il inhibitors biologics(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- hepatitis c daa(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- jak inhibitors(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- il inhibitors biologics(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- tnf inhibitors(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
commercial qhp
- tnf inhibitors(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- il inhibitors biologics(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- hepatitis c daa(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- jak inhibitors(Marketplace QHP (aggregate))PA requiredACA marketplace QHP — aggregated across the state's exchange issuers (PA if any issuer gates the class). Source: CMS machine-readable formulary PUF.
- hepatitis c daa(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Hep C agents and combinations carry PA
- tnf inhibitors(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Anti-TNF mAbs, soluble TNF receptor, and GI TNF blockers all carry PA
- jak inhibitors(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Antirheumatic JAK inhibitors carry PA (5 flags)
- il inhibitors biologics(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. IL-1/IL-1Ra/IL-6/IL-5/anti-IgE and GI IL antagonists all PA
If denied in Texas
📨 Program Support Unit (PSU)
Unlock the full pack
Full criteria, sources & appeal paths — all 51 states.
You’ve seen the breadth and one state in full. The complete Gastroenterologypack — 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.