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Urology care
Auth57 · Specialty PA Pack

Urology

For the urologist on overactive-bladder and testosterone therapy — the PA and appeal map for every payer.

See a free state →Unlock all 51 states →
Structured rules
1,044
PA-required
66%
Appeal layer
51/51
Criteria docs
46/51
The breadth · all 51 jurisdictions

Every state, quantified for urology

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%2458%✓3
COColorado91.8%2259%✓3
OHOhio77.7%2467%✓5
All states · A–Z
AKAlaska—1486%✓1
ALAlabama—2167%✓2
ARArkansas—2467%✓2
AZArizona—2268%✓2
CACalifornia—2454%✓4
CTConnecticut—2268%✓2
DCDistrict of Columbia—2157%✓6
DEDelaware—2268%✓3
FLFlorida—2264%✓1
GAGeorgia—2458%✓4
HIHawaii—2259%✓1
IAIowa—2268%✓5
IDIdaho—1669%✓1
ILIllinois—2065%✓3
INIndiana—2167%✓1
KSKansas—2268%✓3
KYKentucky—2463%✓4
LALouisiana—2075%✓8
MAMassachusetts—1867%✓5
MDMaryland—2060%✓5
MEMaine—2065%✓2
MIMichigan—2070%✓8
MNMinnesota—1675%✓2
MOMissouri—2463%✓—
MSMississippi—2467%✓1
MTMontana—1580%✓2
NCNorth Carolina—2467%✓1
NDNorth Dakota—1567%✓—
NENebraska—2070%✓2
NHNew Hampshire—2070%✓1
NJNew Jersey—2065%✓2
NMNew Mexico—1663%✓—
NVNevada—2065%✓2
NYNew York—2264%✓8
OKOklahoma—2467%✓1
OROregon—2463%✓3
PAPennsylvania—2065%✓10
RIRhode Island—1669%✓—
SCSouth Carolina—2273%✓2
SDSouth Dakota—1464%✓1
TNTennessee—2167%✓4
TXTexas—2467%✓18
UTUtah—2268%✓5
VAVirginia—2357%✓6
VTVermont—1377%✓—
WIWisconsin—2167%✓2
WVWest Virginia—1776%✓1
WYWyoming—1681%✓4
Deep dive· Washington

Washington — urology, 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.
  • testosterone androgensPA 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
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderPA 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
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial regulated
  • overactive bladderUnitedHealthcarePA required▲ Most difficult
    Switch?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.
    Document
    UnitedHealthcare commercial (Advantage 3-Tier). Genitourinary-bladder/genital/kidney; OAB generics open, but mirabegron/ELMIRON/VELPHORO carry ST and VANRAFIA carries PA+QL+SP, TEZRULY PA [e.g. oxybutynin, solifenacin, mirabegron, tolterodine]
    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
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderCignaPA 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
    Cigna commercial (Advantage 3-Tier). urinary tract; OAB generics open (QL), VANRAFIA SP+PA [e.g. oxybutynin er, mirabegron er, solifenacin, tolterodine er]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensAetna (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 + 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. androgens, PA/ST (lab + diagnosis edits) [e.g. testosterone cypionate, testosterone gel, ANDRODERM]
    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
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensUnitedHealthcarePA 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). Hormonal-testosterone replacement; topical gels and brands (KYZATREX, TESTIM) carry PA+QL; injectables open [e.g. testosterone gel, testosterone cypionate, KYZATREX, TESTIM]
    Submit to
    UnitedHealthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensCignaPA 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
    Cigna commercial (Advantage 3-Tier). androgens carry PA+QL (DEPO-TESTOSTERONE open) [e.g. testosterone gel, XYOSTED, DEPO-TESTOSTERONE, testosterone cypionate]
    Submit to
    Cigna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderAetna (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. urinary antispasmodics, open generics; brands ST [e.g. oxybutynin, tolterodine, mirabegron (MYRBETRIQ), solifenacin]
    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
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderAnthem 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. Urinary antispasmodics (antimuscarinics): QL only, NO PA; open [e.g. oxybutynin, tolterodine, trospium, solifenacin]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensAnthem Blue Cross (Elevance)PA 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
    Anthem Blue Cross (Elevance) commercial formulary. Androgens for men carry PA [e.g. danazol, testosterone (androgens)]
    Submit to
    Anthem Blue Cross (Elevance) · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
part d
  • testosterone androgensCentenePA 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
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensHumanaPA 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
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensCignaPA 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
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensAetnaPA 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
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderCenteneNo 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
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensUnitedhealthcareNo 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
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderUnitedhealthcareNo 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
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderHumanaNo 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
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderCignaNo 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
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderAetnaNo 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 Part D (CMS formulary file, plan-grounded).
    Submit to
    Aetna · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensKaiserNo 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
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = Part D patients (Medicare CY2023; infused agents read low).
  • overactive bladderKaiserNo 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
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
commercial qhp
  • overactive bladderMolina HealthcarePA required▲ Most difficult
    Switch?PA + step therapy — a prior in-class trial usually clears it
    This plan gates the class with PA + 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
    Molina Healthcare commercial formulary. Urinary antispasmodics carry 7 ST + 2 PA
    Step therapy
    Document a prior trial/failure (or intolerance) of the plan's preferred in-class agent first.
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Oxybutynin1476KOxybutynin Chloride1476KMyrbetriq763KSolifenacin392KGemtesa320KTolterodine215KTrospium183KMirabegron119KFesoterodine38KFesoterodine Fumarate38KDarifenacin10KToviaz2KVesicare1K
    # = Part D patients (Medicare CY2023; infused agents read low).
  • testosterone androgensMolina 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. methyltestosterone PA+age; testosterone esters QL only
    Submit to
    Molina Healthcare · policy / PA form ↗
    If denied
    Appeal the denial · Office of Administrative Hearings (OAH)
    Brands
    ···
    Testosterone418KTestosterone Cypionate282KXyosted7KJatenzo2KDanazol2KAndrogel818Testopel508Testim245Natesto160Androderm29Methyltestosterone18Kyzatrex0Testosterone Gel0Vogelxo0
    # = 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.