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Pain Management care
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.

See a free state →Unlock all 51 states →
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

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%4558%✓38
COColorado91.8%4154%✓27
OHOhio77.7%4564%✓40
All states · A–Z
AKAlaska—2564%✓10
ALAlabama—3956%✓16
ARArkansas—4764%✓18
AZArizona—4360%✓23
CACalifornia—4560%✓26
CTConnecticut—3964%✓21
DCDistrict of Columbia—4154%✓18
DEDelaware—3959%✓9
FLFlorida—4260%✓11
GAGeorgia—4757%✓79
HIHawaii—4351%✓21
IAIowa—4363%✓13
IDIdaho—2952%✓19
ILIllinois—4057%✓8
INIndiana—4166%✓12
KSKansas—4159%✓39
KYKentucky—4562%✓10
LALouisiana—3667%✓32
MAMassachusetts—3560%✓44
MDMaryland—3551%✓25
MEMaine—3759%✓12
MIMichigan—3759%✓23
MNMinnesota—3063%✓9
MOMissouri—4764%✓22
MSMississippi—4358%✓80
MTMontana—2959%✓9
NCNorth Carolina—4762%✓142
NDNorth Dakota—2959%✓28
NENebraska—3861%✓20
NHNew Hampshire—3560%✓14
NJNew Jersey—3956%✓15
NMNew Mexico—3148%✓22
NVNevada—3656%✓46
NYNew York—4360%✓27
OKOklahoma—4663%✓13
OROregon—4558%✓11
PAPennsylvania—3757%✓172
RIRhode Island—2857%✓12
SCSouth Carolina—3962%✓15
SDSouth Dakota—2756%✓15
TNTennessee—4159%✓16
TXTexas—4560%✓281
UTUtah—4363%✓75
VAVirginia—4558%✓45
VTVermont—2556%✓67
WIWisconsin—4166%✓15
WVWest Virginia—3367%✓11
WYWyoming—2857%✓20
Deep dive· Washington

Washington — pain management, 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.
  • opioid analgesicsPA 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
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderPA 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
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial regulated
  • opioid use disorderUnitedHealthcareNo PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + 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.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). Anti-addiction/substance abuse; QL only, no PA/ST [e.g. buprenorphine-naloxone, ZUBSOLV, naltrexone, NARCAN]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsUnitedHealthcareNo PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + 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.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). Analgesics-pain and inflammation; tier 1-3, only QL on some, no PA/ST [e.g. celecoxib, diclofenac, ibuprofen, meloxicam]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsAetna (CVS Caremark)PA required▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + 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.
    Document
    Aetna (CVS Caremark) commercial formulary. opioids carry QL/ST per CMS opioid safety edits [e.g. morphine, oxycodone, fentanyl, hydromorphone]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsAnthem Blue Cross (Elevance)No PA▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + quantity limit + 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.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. NSAIDs and COX-2: QL/ST only, no PA; open [e.g. diclofenac, ibuprofen, naproxen, celecoxib]
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsUnitedHealthcarePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    UnitedHealthcare 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]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsCignaNo PA
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Cigna commercial (Advantage 3-Tier). oral NSAIDs open (QL); topical FLECTOR/LICART=PA [e.g. meloxicam, celecoxib, diclofenac, naproxen]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderAetna (CVS Caremark)PA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Aetna (CVS Caremark) commercial formulary. opioid agonist/antagonist + antagonist; MOUD, some PA/QL [e.g. buprenorphine-naloxone (SUBOXONE), naltrexone, naloxone]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderAnthem Blue Cross (Elevance)No PA
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit. 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. Opioid partial agonists (buprenorphine): QL only, no PA in this listing [e.g. BRIXADI buprenorphine, buprenorphine sublingual]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsAnthem Blue Cross (Elevance)PA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit. 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. Opioid agonists/combinations carry PA + QL [e.g. hydrocodone-acetaminophen, oxycodone-acetaminophen, codeine combinations, tramadol-acetaminophen]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsUnitedHealthcarePA 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 commercial (Advantage 3-Tier). Skeletal muscle relaxants-muscle pain/spasm; generics open but baclofen oral suspension carries PA [e.g. cyclobenzaprine, baclofen, tizanidine, methocarbamol]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna commercial (Advantage 3-Tier). MOUD/naloxone open, QL only [e.g. buprenorphine-naloxone, naltrexone, NARCAN, ZUBSOLV]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsCignaPA 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 commercial (Advantage 3-Tier). opioids broadly carry PA [e.g. oxycodone ir, morphine er, hydrocodone-acetaminophen, NUCYNTA]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsAnthem Blue Cross (Elevance)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Anthem Blue Cross (Elevance) commercial formulary. Central + direct muscle relaxants: QL only, open [e.g. baclofen, cyclobenzaprine, tizanidine, dantrolene]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Cigna commercial (Advantage 3-Tier). muscle relaxants in pain section, open [e.g. cyclobenzaprine, tizanidine]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsAetna (CVS Caremark)No PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    Document
    Aetna (CVS Caremark) commercial formulary. COX-2 + NSAIDs, mostly open generics; brands NF [e.g. celecoxib, diclofenac, etodolac, meloxicam]
    Submit to
    Aetna (CVS Caremark) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
part d
  • opioid use disorderCentenePA 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
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsCentenePA 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
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsCentenePA 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
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsUnitedhealthcarePA 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
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsHumanaPA 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
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsHumanaPA 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
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsCignaPA 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
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsCignaPA 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
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsAetnaPA 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
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderAetnaPA 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
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsAetnaPA 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
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsAetnaPA 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
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderKaiserPA 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
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsKaiserPA 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
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsCenteneNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderUnitedhealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsUnitedhealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsUnitedhealthcareNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderHumanaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsHumanaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsCignaNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid analgesicsKaiserNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsKaiserNo PA
    Switch?Switch usually clears — no PA
    No prior authorization on this plan for this class — document the clinical reason for the change.
    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
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial qhp
  • opioid analgesicsMolina HealthcarePA required
    Switch?PA required — switch supported by prior therapy
    This plan requires PA + quantity limit. No step therapy is documented for the class, so the switch is reviewed on standard medical-necessity criteria.
    Document
    Molina Healthcare commercial formulary. Opioid agonists carry 11 PA; combos open (QL only)
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Tramadol4152KOxycodone2779KMorphine488KMorphine Sulfate488KHydromorphone213KBuprenorphine141KFentanyl130KMethadone66KOxycontin61KBelbuca38KNucynta14KFentanyl Citrate14KButrans6KHydrocodone3KMs Contin224Nalocet151Diskets0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • opioid use disorderMolina 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. Opioid partial agonists (buprenorphine) carry 2 PA; antagonists open
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Naloxone604KBuprenorphine141KNaltrexone139KSuboxone18KVivitrol10KNarcan8KZubsolv6KSublocade5KBrixadi2KLucemyra446
    # = Part D patients (Medicare CY2023; infused agents read low).
  • nsaidsMolina 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. meclofenamate/mefenamic/fenoprofen carry PA; common NSAIDs open
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Meloxicam4121KIbuprofen3621KDiclofenac2832KDiclofenac Sodium2627KCelecoxib1859KNaproxen1396KEtodolac105KCelebrex3KFlector629Elyxyb479Arthrotec183Duexis91Naprelan16Addaprin0Advil0Journavx0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • skeletal muscle relaxantsMolina 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. Central muscle relaxants carry 1 PA; direct/combos open
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Cyclobenzaprine2726KTizanidine2072KBaclofen1358KMethocarbamol1343KMetaxalone28KDantrolene7KAmrix33
    # = Part D patients (Medicare CY2023; infused agents read low).
If denied in Washington
📨 Office of Administrative Hearings (OAH)
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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.