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 | Rules | PA-required | Appeal | Criteria docs |
|---|---|---|---|---|
| AKAlaska | 14 | 86% | ✓ | 6 |
| ALAlabama | 18 | 89% | ✓ | 1 |
| ARArkansas | 19 | 89% | ✓ | 7 |
| AZArizona | 19 | 89% | ✓ | 6 |
| CACalifornia | 25 | 88% | ✓ | 15 |
| COColorado | 18 | 89% | ✓ | 2 |
| 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 |
| OHOhio | 21 | 95% | ✓ | 10 |
| 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 |
| WAWashington | 19 | 89% | ✓ | 13 |
| WIWisconsin | 18 | 89% | ✓ | 10 |
| WVWest Virginia | 16 | 88% | ✓ | 4 |
| WYWyoming | 15 | 87% | ✓ | 1 |
Free preview· Texas
What a fully-unlocked state looks like
medicare advantage
- oncology oralPA requiredPart D protected class. Broad access required.
commercial regulated
- oncology oral(Aetna (CVS Caremark))PA requiredstep therapyAetna (CVS Caremark) commercial formulary. oral antineoplastics (alkylating/antimetabolites/BCL-2/kinase/proteasome/topoisomerase), specialty PA [e.g. kinase inhibitors, VENCLEXTA, temozolomide, imatinib]
- oncology oral(Oscar Health)PA requiredstep therapySpecialty tier; covered if FDA-approved or NCCN cat 1/2A/2B; preferred-product logic on select agents.
- oncology oral(UnitedHealthcare)PA requiredstep therapyUnitedHealthcare commercial (Advantage 3-Tier). Antineoplastics-cancer; nearly all brand oral oncolytics carry PA+QL+SP; generics (anastrozole, tamoxifen) H-PA only [e.g. ALECENSA, CALQUENCE, LYNPARZA, TAGRISSO]
- oncology oral(Cigna)PA requiredCigna commercial (Advantage 3-Tier). oral oncolytics SP+PA throughout cancer section [e.g. IBRANCE, IMBRUVICA, VERZENIO, XTANDI]
- oncology supportive(Aetna (CVS Caremark))PA requiredAetna (CVS Caremark) commercial formulary. protective/supportive oncology agents [e.g. leucovorin, mesna, protective agents]
- oncology oral(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Oral antineoplastics (ALK/BCR-ABL/BRAF/BTK/EGFR/MEK/mTOR/CDK/PARP/PI3K/multikinase/immunomodulators/antimetabolites/LHRH): PA + SP [e.g. capecitabine, IMBRUVICA ibrutinib, TAFINLAR dabrafenib, IBRANCE palbociclib]
commercial qhp
- oncology oral(Ambetter / Superior HealthPlan (Centene))PA requiredstep therapySpecialty tier; covered if FDA-approved or NCCN cat 1/2A/2B; preferred-product logic on select agents.
- oncology oral(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.
- oncology supportive(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. ESAs and TPO receptor agonists carry PA; 5-HT3 antiemetic 1 PA
- oncology oral(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Antineoplastics block: 86 PA flags across kinase inhibitors etc
medicaid mco
- oncology oralPA requiredDiagnosis requiredOncologist attestation required
medicare traditional
- oncology oralNo PAOral agents Part D PDP. IV/infused Part B — no PA under FFS.
medicaid ffs
- oncology oral(FFS)PA requiredCorrected to PA-required via cross-state consensus + source re-verification: clinical judgment, low confidence (no source); 93% cross-state norm
dual eligible
- oncology oralNo PAPart D primary — protected class. LIS eliminates cost-sharing.
part d
- oncology oralNo PAFEDERAL PROTECTED CLASS. Broad access required.
- oncology oral(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- oncology oral(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- oncology oral(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- oncology oral(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- oncology oral(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
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 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.