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Allergy / Immunology care
Auth57 · Specialty PA Pack

Allergy / Immunology

For the allergist running asthma biologics and immunoglobulin — PA rules and appeal paths, every state.

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Structured rules
634
PA-required
100%
Appeal layer
51/51
Criteria docs
47/51
The breadth · all 51 jurisdictions

Every state, quantified for allergy / immunology

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%14100%✓2
COColorado91.8%14100%✓5
OHOhio77.7%14100%✓7
All states · A–Z
AKAlaska—9100%✓4
ALAlabama—13100%✓5
ARArkansas—15100%✓3
AZArizona—14100%✓2
CACalifornia—14100%✓9
CTConnecticut—12100%✓2
DCDistrict of Columbia—12100%✓2
DEDelaware—14100%✓3
FLFlorida—13100%✓3
GAGeorgia—14100%✓7
HIHawaii—14100%✓4
IAIowa—1392%✓5
IDIdaho—11100%✓6
ILIllinois—13100%✓3
INIndiana—13100%✓5
KSKansas—12100%✓23
KYKentucky—13100%✓5
LALouisiana—11100%✓15
MAMassachusetts—12100%✓2
MDMaryland—11100%✓5
MEMaine—13100%✓2
MIMichigan—12100%✓11
MNMinnesota—10100%✓1
MOMissouri—14100%✓3
MSMississippi—15100%✓28
MTMontana—10100%✓2
NCNorth Carolina—14100%✓12
NDNorth Dakota—10100%✓1
NENebraska—12100%✓4
NHNew Hampshire—12100%✓—
NJNew Jersey—12100%✓2
NMNew Mexico—10100%✓—
NVNevada—12100%✓12
NYNew York—13100%✓10
OKOklahoma—14100%✓3
OROregon—13100%✓3
PAPennsylvania—12100%✓15
RIRhode Island—10100%✓—
SCSouth Carolina—13100%✓2
SDSouth Dakota—9100%✓2
TNTennessee—13100%✓1
TXTexas—15100%✓25
UTUtah—14100%✓6
VAVirginia—14100%✓5
VTVermont—9100%✓2
WIWisconsin—13100%✓4
WVWest Virginia—11100%✓—
WYWyoming—10100%✓4
Deep dive· Washington

Washington — allergy / immunology, 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 ↗
Plan
Show
medicaid ffs
Approved · CMS-0057-F 202554.8%
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.
  • asthma copd biologicsPA required
    Switch?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.
    Document
    WA Medicaid PDL: non-preferred agents in this class require PA.
    Submit to
    the plan · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial regulated
  • asthma copd biologicsUnitedHealthcarePA required▲ Most difficult
    Switch?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.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). Asthma/COPD biologic subset within asthma/COPD heading; all carry PA+QL+SP [e.g. FASENRA, NUCALA, TEZSPIRE, XOLAIR]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • asthma copd biologicsCignaPA required
    Switch?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.
    Document
    Cigna commercial (Advantage 3-Tier). respiratory biologics carry SP+PA [e.g. FASENRA PEN, NUCALA, TEZSPIRE, XOLAIR]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • immunoglobulinsAetna (CVS Caremark)PA required
    Switch?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.
    Document
    Aetna (CVS Caremark) commercial formulary. immunoglobulin, specialty PA [e.g. IVIG / SCIG (GAMMAGARD, HIZENTRA, PRIVIGEN)]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Gammagard5KPrivigen4KOctagam3KHizentra2KGammaplex2KGammaked2KCuvitru502Bivigam38
    # = Part D patients (Medicare CY2023; infused agents read low).
  • asthma copd biologicsAetna (CVS Caremark)PA required
    Switch?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.
    Document
    Aetna (CVS Caremark) commercial formulary. severe asthma biologics, specialty PA [e.g. omalizumab (XOLAIR), mepolizumab (NUCALA), benralizumab (FASENRA), dupilumab]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • immunoglobulinsAnthem Blue Cross (Elevance)PA required
    Switch?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.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. Passive immunizing agents (IG combinations): PA + SP [e.g. HYQVIA immune globulin]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Gammagard5KPrivigen4KOctagam3KHizentra2KGammaplex2KGammaked2KCuvitru502Bivigam38
    # = Part D patients (Medicare CY2023; infused agents read low).
part d
  • asthma copd biologicsCentenePA required
    Switch?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.
    Document
    Centene Part D (CMS formulary file, plan-grounded).
    Submit to
    Centene · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • asthma copd biologicsUnitedhealthcarePA required
    Switch?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.
    Document
    Unitedhealthcare Part D (CMS formulary file, plan-grounded).
    Submit to
    Unitedhealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • asthma copd biologicsHumanaPA required
    Switch?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.
    Document
    Humana Part D (CMS formulary file, plan-grounded).
    Submit to
    Humana · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • asthma copd biologicsCignaPA required
    Switch?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.
    Document
    Cigna Part D (CMS formulary file, plan-grounded).
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • asthma copd biologicsAetnaPA required
    Switch?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.
    Document
    Aetna Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • asthma copd biologicsKaiserPA required
    Switch?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.
    Document
    Kaiser Part D (CMS formulary file, plan-grounded).
    Submit to
    Kaiser · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial qhp
  • asthma copd biologicsMolina HealthcarePA required
    Switch?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.
    Document
    Molina Healthcare commercial formulary. Anti-IgE and IL-5 antagonist respiratory biologics carry PA
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Dupixent88KFasenra12KXolair11KNucala9KTezspire6KNemluvio967Cinqair26
    # = Part D patients (Medicare CY2023; infused agents read low).
  • immunoglobulinsMolina HealthcarePA required
    Switch?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.
    Document
    Molina Healthcare commercial formulary. Immune serums (IVIG/SCIG) carry 12 PA
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Gammagard5KPrivigen4KOctagam3KHizentra2KGammaplex2KGammaked2KCuvitru502Bivigam38
    # = Part D patients (Medicare CY2023; infused agents read low).
If denied in Washington
📨 Office of Administrative Hearings (OAH)
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Full criteria, sources & appeal paths — all 51 states.

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Assembled from Auth57’s rules + criteria corpus + 51-state appeal layer. Draft data — verify against the payer’s current policy before relying.