Auth57 · Specialty PA Pack

Oncology

For the oncology team on oral chemo and supportive care — prior auth and appeals, mapped nationwide.

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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	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	19	89%	✓	13
COColorado	91.8%	18	89%	✓	2
OHOhio	77.7%	21	95%	✓	10
All states · A–Z
AKAlaska	—	14	86%	✓	6
ALAlabama	—	18	89%	✓	1
ARArkansas	—	19	89%	✓	7
AZArizona	—	19	89%	✓	6
CACalifornia	—	25	88%	✓	15
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
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
WIWisconsin	—	18	89%	✓	10
WVWest Virginia	—	16	88%	✓	4
WYWyoming	—	15	87%	✓	1

Deep dive· Washington

Washington — oncology, 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 mco

Approved · CMS-0057-F 202588.2%across 4 payers (81.2–93.1%)

Draft · aggregatedSource ↗

oncology oralPA 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

oncology oral(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.
oncology oral(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.
oncology oral(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.
oncology supportive(Aetna (CVS Caremark))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.
oncology oral(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.

dual eligible

oncology oralPA 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.

medicaid ffs

Approved · CMS-0057-F 202554.8%

oncology oralPA 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.

medicare advantage

oncology oralPA 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.

medicare traditional

oncology oralNo PA
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.

part d

oncology oralNo PA
Switching a patient to this agent?
Switch usually clears — no PA
No prior authorization on this plan for this class — document the clinical reason for the change.
oncology oral(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.
oncology oral(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.
oncology oral(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.
oncology oral(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.
oncology oral(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.
oncology oral(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

oncology oral(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.
oncology supportive(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 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.