Auth57 · Specialty PA Pack

Retina / Ophthalmology

For the retina specialist injecting anti-VEGF — the prior-auth and appeal map across all 51 states.

See a free state →Unlock all 51 states →

Structured rules

109

PA-required

50%

Appeal layer

51/51

Criteria docs

30/51

The breadth · all 51 jurisdictions

Every state, quantified for retina / ophthalmology

State	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	2	50%	✓	5
COColorado	91.8%	2	50%	✓	9
OHOhio	77.7%	2	50%	✓	1
All states · A–Z
AKAlaska	—	2	50%	✓	—
ALAlabama	—	2	50%	✓	1
ARArkansas	—	2	50%	✓	1
AZArizona	—	2	50%	✓	2
CACalifornia	—	2	50%	✓	6
CTConnecticut	—	2	50%	✓	—
DCDistrict of Columbia	—	3	67%	✓	—
DEDelaware	—	2	50%	✓	—
FLFlorida	—	3	33%	✓	1
GAGeorgia	—	2	50%	✓	1
HIHawaii	—	2	50%	✓	—
IAIowa	—	2	50%	✓	1
IDIdaho	—	2	50%	✓	—
ILIllinois	—	2	50%	✓	3
INIndiana	—	2	50%	✓	2
KSKansas	—	2	50%	✓	2
KYKentucky	—	2	50%	✓	1
LALouisiana	—	2	50%	✓	4
MAMassachusetts	—	3	67%	✓	—
MDMaryland	—	2	50%	✓	—
MEMaine	—	2	50%	✓	1
MIMichigan	—	3	33%	✓	2
MNMinnesota	—	2	50%	✓	—
MOMissouri	—	2	50%	✓	—
MSMississippi	—	2	50%	✓	—
MTMontana	—	2	50%	✓	—
NCNorth Carolina	—	2	50%	✓	1
NDNorth Dakota	—	2	50%	✓	—
NENebraska	—	2	50%	✓	—
NHNew Hampshire	—	2	50%	✓	—
NJNew Jersey	—	3	33%	✓	1
NMNew Mexico	—	2	50%	✓	—
NVNevada	—	2	50%	✓	—
NYNew York	—	2	50%	✓	5
OKOklahoma	—	3	33%	✓	1
OROregon	—	2	50%	✓	1
PAPennsylvania	—	3	67%	✓	6
RIRhode Island	—	2	50%	✓	—
SCSouth Carolina	—	2	50%	✓	1
SDSouth Dakota	—	2	50%	✓	—
TNTennessee	—	2	50%	✓	2
TXTexas	—	2	50%	✓	2
UTUtah	—	2	50%	✓	1
VAVirginia	—	2	50%	✓	1
VTVermont	—	2	50%	✓	2
WIWisconsin	—	2	50%	✓	2
WVWest Virginia	—	2	50%	✓	—
WYWyoming	—	2	50%	✓	—

Deep dive· Washington

Washington — retina / ophthalmology, 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

commercial regulated

ophthalmic anti vegfAetna (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. retinal disorders anti-VEGF, specialty/medical PA [e.g. aflibercept (EYLEA), ranibizumab (LUCENTIS), faricimab]
Submit to
Aetna (CVS Caremark) · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Eylea8KVabysmo2KLucentis332Beovu42Cimerli40Byooviz0
# = Part D patients (Medicare CY2023; infused agents read low).

commercial qhp

ophthalmic anti vegfMolina HealthcareNo PA
Switch?Switch usually clears — no PA
No prior authorization on this plan for this class — document the clinical reason for the change.
Document
Molina Healthcare commercial formulary. No oral/pharmacy anti-VEGF (Eylea/Lucentis) on this outpatient formulary
Submit to
Molina Healthcare · policy / PA form ↗
If denied
Appeal the denial · Office of Administrative Hearings (OAH)
Brands
···
Eylea8KVabysmo2KLucentis332Beovu42Cimerli40Byooviz0
# = Part D patients (Medicare CY2023; infused agents read low).

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 Retina / Ophthalmologypack — 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.