Auth57 · Specialty PA Pack
Pain Management
For the pain practice navigating opioids, MME limits, and OUD therapy — what needs PA and how to clear it.
Structured rules
1,970
PA-required
59%
Appeal layer
51/51
Criteria docs
51/51
The breadth · all 51 jurisdictions
Every state, quantified for pain management
| State | Rules | PA-required | Appeal | Criteria docs |
|---|---|---|---|---|
| AKAlaska | 25 | 64% | ✓ | 10 |
| ALAlabama | 39 | 56% | ✓ | 16 |
| ARArkansas | 47 | 64% | ✓ | 18 |
| AZArizona | 43 | 60% | ✓ | 23 |
| CACalifornia | 45 | 60% | ✓ | 26 |
| COColorado | 41 | 54% | ✓ | 27 |
| CTConnecticut | 39 | 64% | ✓ | 21 |
| DCDistrict of Columbia | 41 | 54% | ✓ | 18 |
| DEDelaware | 39 | 59% | ✓ | 9 |
| FLFlorida | 42 | 60% | ✓ | 11 |
| GAGeorgia | 47 | 57% | ✓ | 79 |
| HIHawaii | 43 | 51% | ✓ | 21 |
| IAIowa | 43 | 63% | ✓ | 13 |
| IDIdaho | 29 | 52% | ✓ | 19 |
| ILIllinois | 40 | 57% | ✓ | 8 |
| INIndiana | 41 | 66% | ✓ | 12 |
| KSKansas | 41 | 59% | ✓ | 39 |
| KYKentucky | 45 | 62% | ✓ | 10 |
| LALouisiana | 36 | 67% | ✓ | 32 |
| MAMassachusetts | 35 | 60% | ✓ | 44 |
| MDMaryland | 35 | 51% | ✓ | 25 |
| MEMaine | 37 | 59% | ✓ | 12 |
| MIMichigan | 37 | 59% | ✓ | 23 |
| MNMinnesota | 30 | 63% | ✓ | 9 |
| MOMissouri | 47 | 64% | ✓ | 22 |
| MSMississippi | 43 | 58% | ✓ | 80 |
| MTMontana | 29 | 59% | ✓ | 9 |
| NCNorth Carolina | 47 | 62% | ✓ | 142 |
| NDNorth Dakota | 29 | 59% | ✓ | 28 |
| NENebraska | 38 | 61% | ✓ | 20 |
| NHNew Hampshire | 35 | 60% | ✓ | 14 |
| NJNew Jersey | 39 | 56% | ✓ | 15 |
| NMNew Mexico | 31 | 48% | ✓ | 22 |
| NVNevada | 36 | 56% | ✓ | 46 |
| NYNew York | 43 | 60% | ✓ | 27 |
| OHOhio | 45 | 64% | ✓ | 40 |
| OKOklahoma | 46 | 63% | ✓ | 13 |
| OROregon | 45 | 58% | ✓ | 11 |
| PAPennsylvania | 37 | 57% | ✓ | 172 |
| RIRhode Island | 28 | 57% | ✓ | 12 |
| SCSouth Carolina | 39 | 62% | ✓ | 15 |
| SDSouth Dakota | 27 | 56% | ✓ | 15 |
| TNTennessee | 41 | 59% | ✓ | 16 |
| TXTexas | 45 | 60% | ✓ | 281 |
| UTUtah | 43 | 63% | ✓ | 75 |
| VAVirginia | 45 | 58% | ✓ | 45 |
| VTVermont | 25 | 56% | ✓ | 67 |
| WAWashington | 45 | 58% | ✓ | 38 |
| WIWisconsin | 41 | 66% | ✓ | 15 |
| WVWest Virginia | 33 | 67% | ✓ | 11 |
| WYWyoming | 28 | 57% | ✓ | 20 |
Free preview· Texas
What a fully-unlocked state looks like
medicaid ffs
- opioid use disorderNo PATX Medicaid: ALL-PREFERRED / protected class — no PDL prior authorization. Source: Acentra TX PDL Criteria Guide 2026-01-30 (official companion to TX Medicaid PDL).
- opioid analgesicsPA 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
- opioid use disorder(UnitedHealthcare)No PAUnitedHealthcare commercial (Advantage 3-Tier). Anti-addiction/substance abuse; QL only, no PA/ST [e.g. buprenorphine-naloxone, ZUBSOLV, naltrexone, NARCAN]
- opioid analgesics(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). Analgesics-pain; several agents carry PA (BELBUCA, morphine ER, NUCYNTA ER, lidocaine patch) plus QL [e.g. BELBUCA, buprenorphine, morphine sulfate er, NUCYNTA ER]
- skeletal muscle relaxants(UnitedHealthcare)PA requiredUnitedHealthcare commercial (Advantage 3-Tier). Skeletal muscle relaxants-muscle pain/spasm; generics open but baclofen oral suspension carries PA [e.g. cyclobenzaprine, baclofen, tizanidine, methocarbamol]
- nsaids(UnitedHealthcare)No PAUnitedHealthcare commercial (Advantage 3-Tier). Analgesics-pain and inflammation; tier 1-3, only QL on some, no PA/ST [e.g. celecoxib, diclofenac, ibuprofen, meloxicam]
- opioid use disorder(Cigna)No PACigna commercial (Advantage 3-Tier). MOUD/naloxone open, QL only [e.g. buprenorphine-naloxone, naltrexone, NARCAN, ZUBSOLV]
- nsaids(Cigna)No PACigna commercial (Advantage 3-Tier). oral NSAIDs open (QL); topical FLECTOR/LICART=PA [e.g. meloxicam, celecoxib, diclofenac, naproxen]
- opioid analgesics(Cigna)PA requiredCigna commercial (Advantage 3-Tier). opioids broadly carry PA [e.g. oxycodone ir, morphine er, hydrocodone-acetaminophen, NUCYNTA]
- skeletal muscle relaxants(Cigna)No PACigna commercial (Advantage 3-Tier). muscle relaxants in pain section, open [e.g. cyclobenzaprine, tizanidine]
- nsaids(Aetna (CVS Caremark))No PAAetna (CVS Caremark) commercial formulary. COX-2 + NSAIDs, mostly open generics; brands NF [e.g. celecoxib, diclofenac, etodolac, meloxicam]
- opioid analgesics(Aetna (CVS Caremark))PA requiredAetna (CVS Caremark) commercial formulary. opioids carry QL/ST per CMS opioid safety edits [e.g. morphine, oxycodone, fentanyl, hydromorphone]
- opioid use disorder(Aetna (CVS Caremark))PA requiredAetna (CVS Caremark) commercial formulary. opioid agonist/antagonist + antagonist; MOUD, some PA/QL [e.g. buprenorphine-naloxone (SUBOXONE), naltrexone, naloxone]
- opioid use disorder(Anthem Blue Cross (Elevance))No PAAnthem Blue Cross (Elevance) commercial formulary. Opioid partial agonists (buprenorphine): QL only, no PA in this listing [e.g. BRIXADI buprenorphine, buprenorphine sublingual]
- nsaids(Anthem Blue Cross (Elevance))No PAAnthem Blue Cross (Elevance) commercial formulary. NSAIDs and COX-2: QL/ST only, no PA; open [e.g. diclofenac, ibuprofen, naproxen, celecoxib]
- skeletal muscle relaxants(Anthem Blue Cross (Elevance))No PAAnthem Blue Cross (Elevance) commercial formulary. Central + direct muscle relaxants: QL only, open [e.g. baclofen, cyclobenzaprine, tizanidine, dantrolene]
- opioid analgesics(Anthem Blue Cross (Elevance))PA requiredAnthem Blue Cross (Elevance) commercial formulary. Opioid agonists/combinations carry PA + QL [e.g. hydrocodone-acetaminophen, oxycodone-acetaminophen, codeine combinations, tramadol-acetaminophen]
part d
- opioid use disorder(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- nsaids(Centene)No PACentene Part D (CMS formulary file, plan-grounded).
- opioid analgesics(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- skeletal muscle relaxants(Centene)PA requiredCentene Part D (CMS formulary file, plan-grounded).
- opioid use disorder(Unitedhealthcare)No PAUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- nsaids(Unitedhealthcare)PA requiredUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- skeletal muscle relaxants(Unitedhealthcare)No PAUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- opioid analgesics(Unitedhealthcare)No PAUnitedhealthcare Part D (CMS formulary file, plan-grounded).
- opioid use disorder(Humana)No PAHumana Part D (CMS formulary file, plan-grounded).
- opioid analgesics(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- nsaids(Humana)PA requiredHumana Part D (CMS formulary file, plan-grounded).
- skeletal muscle relaxants(Humana)No PAHumana Part D (CMS formulary file, plan-grounded).
- nsaids(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- opioid analgesics(Cigna)No PACigna Part D (CMS formulary file, plan-grounded).
- opioid use disorder(Cigna)No PACigna Part D (CMS formulary file, plan-grounded).
- skeletal muscle relaxants(Cigna)PA requiredCigna Part D (CMS formulary file, plan-grounded).
- opioid use disorder(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- skeletal muscle relaxants(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- opioid analgesics(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
- nsaids(Aetna)PA requiredAetna Part D (CMS formulary file, plan-grounded).
commercial qhp
- opioid analgesics(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.
- nsaids(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.
- skeletal muscle relaxants(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.
- opioid use disorder(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.
- opioid use disorder(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Opioid partial agonists (buprenorphine) carry 2 PA; antagonists open
- opioid analgesics(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Opioid agonists carry 11 PA; combos open (QL only)
- nsaids(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. meclofenamate/mefenamic/fenoprofen carry PA; common NSAIDs open
- skeletal muscle relaxants(Molina Healthcare)PA requiredMolina Healthcare commercial formulary. Central muscle relaxants carry 1 PA; direct/combos open
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 Pain Managementpack — 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.