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.

Unlock all 51 states →See a free state →

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	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	44	100%	✓	9
COColorado	91.8%	40	93%	✓	11
OHOhio	77.7%	46	100%	✓	12
All states · A–Z
AKAlaska	—	26	100%	✓	3
ALAlabama	—	42	100%	✓	4
ARArkansas	—	44	100%	✓	5
AZArizona	—	40	100%	✓	2
CACalifornia	—	46	91%	✓	7
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
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
WIWisconsin	—	40	100%	✓	2
WVWest Virginia	—	33	100%	✓	—
WYWyoming	—	27	100%	✓	5

Deep dive· Washington

Washington — gastroenterology, 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
Switching a patient to this agent?
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.
hepatitis c daaPA required
Switching a patient to this agent?
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.

commercial regulated

hepatitis c daa(UnitedHealthcare)PA required
Switching a patient to this agent?
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.
tnf inhibitors(UnitedHealthcare)PA required
Switching a patient to this agent?
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.
il inhibitors biologics(UnitedHealthcare)PA required
Switching a patient to this agent?
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.
jak inhibitors(UnitedHealthcare)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Cigna)PA required
Switching a patient to this agent?
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.
tnf inhibitors(Cigna)PA required
Switching a patient to this agent?
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.
jak inhibitors(Cigna)PA required
Switching a patient to this agent?
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.
il inhibitors biologics(Cigna)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Aetna (CVS Caremark))PA required
Switching a patient to this agent?
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.
tnf inhibitors(Aetna (CVS Caremark))PA required
Switching a patient to this agent?
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.
il inhibitors biologics(Anthem Blue Cross (Elevance))PA required
Switching a patient to this agent?
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.
tnf inhibitors(Anthem Blue Cross (Elevance))PA required
Switching a patient to this agent?
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.
jak inhibitors(Anthem Blue Cross (Elevance))PA required
Switching a patient to this agent?
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.
hepatitis c daa(Anthem Blue Cross (Elevance))PA required
Switching a patient to this agent?
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.

part d

jak inhibitors(Centene)PA required
Switching a patient to this agent?
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.
tnf inhibitors(Centene)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Centene)PA required
Switching a patient to this agent?
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.
il inhibitors biologics(Centene)PA required
Switching a patient to this agent?
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.
jak inhibitors(Unitedhealthcare)PA required
Switching a patient to this agent?
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.
il inhibitors biologics(Unitedhealthcare)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Unitedhealthcare)PA required
Switching a patient to this agent?
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.
tnf inhibitors(Unitedhealthcare)PA required
Switching a patient to this agent?
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.
jak inhibitors(Humana)PA required
Switching a patient to this agent?
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.
il inhibitors biologics(Humana)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Humana)PA required
Switching a patient to this agent?
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.
tnf inhibitors(Humana)PA required
Switching a patient to this agent?
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.
tnf inhibitors(Cigna)PA required
Switching a patient to this agent?
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.
jak inhibitors(Cigna)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Cigna)PA required
Switching a patient to this agent?
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.
il inhibitors biologics(Cigna)PA required
Switching a patient to this agent?
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.
tnf inhibitors(Aetna)PA required
Switching a patient to this agent?
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.
jak inhibitors(Aetna)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Aetna)PA required
Switching a patient to this agent?
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.
il inhibitors biologics(Aetna)PA required
Switching a patient to this agent?
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.
jak inhibitors(Kaiser)PA required
Switching a patient to this agent?
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.
tnf inhibitors(Kaiser)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Kaiser)PA required
Switching a patient to this agent?
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.
il inhibitors biologics(Kaiser)PA required
Switching a patient to this agent?
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.

commercial qhp

il inhibitors biologics(Molina Healthcare)PA required
Switching a patient to this agent?
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.
hepatitis c daa(Molina Healthcare)PA required
Switching a patient to this agent?
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.
tnf inhibitors(Molina Healthcare)PA required
Switching a patient to this agent?
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.
jak inhibitors(Molina Healthcare)PA required
Switching a patient to this agent?
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.

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 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.