Auth57 · Specialty PA Pack

Gastroenterology

For the GI practice running IBD biologics and Hep C therapy — what needs prior auth, and how to win the appeal.

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Structured rules

1,955

PA-required

99%

Appeal layer

51/51

Criteria docs

47/51

The breadth · all 51 jurisdictions

Every state, quantified for gastroenterology

State	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	44	100%	✓	9
COColorado	91.8%	40	93%	✓	11
OHOhio	77.7%	46	100%	✓	12
All states · A–Z
AKAlaska	—	26	100%	✓	3
ALAlabama	—	42	100%	✓	4
ARArkansas	—	44	100%	✓	5
AZArizona	—	40	100%	✓	2
CACalifornia	—	46	91%	✓	7
CTConnecticut	—	41	100%	✓	4
DCDistrict of Columbia	—	41	93%	✓	4
DEDelaware	—	39	100%	✓	4
FLFlorida	—	42	100%	✓	2
GAGeorgia	—	45	93%	✓	11
HIHawaii	—	42	88%	✓	5
IAIowa	—	39	100%	✓	7
IDIdaho	—	30	100%	✓	2
ILIllinois	—	40	100%	✓	3
INIndiana	—	39	100%	✓	3
KSKansas	—	41	100%	✓	18
KYKentucky	—	45	100%	✓	5
LALouisiana	—	37	100%	✓	8
MAMassachusetts	—	34	100%	✓	1
MDMaryland	—	36	92%	✓	6
MEMaine	—	36	100%	✓	4
MIMichigan	—	38	97%	✓	13
MNMinnesota	—	30	100%	✓	4
MOMissouri	—	49	100%	✓	3
MSMississippi	—	45	100%	✓	10
MTMontana	—	28	100%	✓	2
NCNorth Carolina	—	45	100%	✓	16
NDNorth Dakota	—	29	100%	✓	1
NENebraska	—	36	100%	✓	2
NHNew Hampshire	—	36	100%	✓	—
NJNew Jersey	—	37	100%	✓	2
NMNew Mexico	—	30	100%	✓	—
NVNevada	—	36	100%	✓	11
NYNew York	—	42	100%	✓	12
OKOklahoma	—	46	100%	✓	2
OROregon	—	43	93%	✓	3
PAPennsylvania	—	38	100%	✓	14
RIRhode Island	—	28	100%	✓	1
SCSouth Carolina	—	40	100%	✓	6
SDSouth Dakota	—	26	100%	✓	—
TNTennessee	—	41	100%	✓	3
TXTexas	—	46	100%	✓	73
UTUtah	—	42	100%	✓	16
VAVirginia	—	44	93%	✓	4
VTVermont	—	25	100%	✓	1
WIWisconsin	—	40	100%	✓	2
WVWest Virginia	—	33	100%	✓	—
WYWyoming	—	27	100%	✓	5

Deep dive· Washington

Washington — gastroenterology, 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 ffs

Approved · CMS-0057-F 202554.8%

jak inhibitorsPA required
WA Medicaid PDL: non-preferred agents in this class require PA.
hepatitis c daaPA required
WA Medicaid PDL: non-preferred agents in this class require PA.

commercial regulated

hepatitis c daa(UnitedHealthcare)PA required
UnitedHealthcare commercial (Advantage 3-Tier). Hep C DAAs within Antivirals heading; all carry PA+QL+SP (HARVONI/LEDIPASVIR-SOFOSBUVIR add ST) [e.g. EPCLUSA, HARVONI, MAVYRET, VOSEVI]
tnf inhibitors(UnitedHealthcare)PA required
UnitedHealthcare commercial (Advantage 3-Tier). TNF inhibitor subset within Immunological heading; all carry PA+QL+SP [e.g. HUMIRA, ENBREL, CIMZIA, SIMPONI]
il inhibitors biologics(UnitedHealthcare)PA required
UnitedHealthcare commercial (Advantage 3-Tier). IL inhibitor subset within Immunological heading; all carry PA+QL+SP (some +ST) [e.g. COSENTYX, SKYRIZI, BIMZELX, OMVOH]
jak inhibitors(UnitedHealthcare)PA required
UnitedHealthcare commercial (Advantage 3-Tier). JAK inhibitor subset within Immunological heading; all carry PA+QL+SP [e.g. RINVOQ, XELJANZ, XELJANZ XR, OLUMIANT]
hepatitis c daa(Cigna)PA required
Cigna commercial (Advantage 3-Tier). HCV direct-acting antivirals SP+PA [e.g. EPCLUSA, HARVONI, VOSEVI, ZEPATIER]
tnf inhibitors(Cigna)PA required
Cigna commercial (Advantage 3-Tier). TNF inhibitors SP+PA in pain/inflammatory section [e.g. HUMIRA, ENBREL, INFLECTRA, CIMZIA]
jak inhibitors(Cigna)PA required
Cigna commercial (Advantage 3-Tier). JAK/TYK2 inhibitors SP+PA [e.g. RINVOQ, XELJANZ, OLUMIANT, SOTYKTU]
il inhibitors biologics(Cigna)PA required
Cigna commercial (Advantage 3-Tier). IL-17/23/etc biologics SP+PA [e.g. COSENTYX, TALTZ, SKYRIZI, TREMFYA]
hepatitis c daa(Aetna (CVS Caremark))PA required
Aetna (CVS Caremark) commercial formulary. HCV DAAs, specialty, PA standard [e.g. MAVYRET, EPCLUSA, sofosbuvir-velpatasvir, ZEPATIER]
tnf inhibitors(Aetna (CVS Caremark))PA required
Aetna (CVS Caremark) commercial formulary. self-administered autoimmune biologics + JAK (TNF/IL/JAK), specialty PSP, PA/ST [e.g. HUMIRA, ENBREL, DUPIXENT, SKYRIZI]
il inhibitors biologics(Anthem Blue Cross (Elevance))PA required
Anthem Blue Cross (Elevance) commercial formulary. Interleukin antagonists + costimulation modulators: PA/SP (some ST) [e.g. STELARA, SKYRIZI, ustekinumab, ORENCIA abatacept]
tnf inhibitors(Anthem Blue Cross (Elevance))PA required
Anthem Blue Cross (Elevance) commercial formulary. Soluble TNF receptor + anti-TNF monoclonals: PA/SP [e.g. ENBREL, HUMIRA, etanercept, adalimumab]
jak inhibitors(Anthem Blue Cross (Elevance))PA required
Anthem Blue Cross (Elevance) commercial formulary. Antirheumatic JAK + oncology JAK: PA/SP [e.g. RINVOQ, XELJANZ, upadacitinib, JAKAFI ruxolitinib]
hepatitis c daa(Anthem Blue Cross (Elevance))PA required
Anthem Blue Cross (Elevance) commercial formulary. Hepatitis C agents + combinations: PA + SP [e.g. EPCLUSA sofosbuvir-velpatasvir, PEGASYS peginterferon]

part d

jak inhibitors(Centene)PA required
Centene Part D (CMS formulary file, plan-grounded).
tnf inhibitors(Centene)PA required
Centene Part D (CMS formulary file, plan-grounded).
hepatitis c daa(Centene)PA required
Centene Part D (CMS formulary file, plan-grounded).
il inhibitors biologics(Centene)PA required
Centene Part D (CMS formulary file, plan-grounded).
jak inhibitors(Unitedhealthcare)PA required
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
il inhibitors biologics(Unitedhealthcare)PA required
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
hepatitis c daa(Unitedhealthcare)PA required
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
tnf inhibitors(Unitedhealthcare)PA required
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
jak inhibitors(Humana)PA required
Humana Part D (CMS formulary file, plan-grounded).
il inhibitors biologics(Humana)PA required
Humana Part D (CMS formulary file, plan-grounded).
hepatitis c daa(Humana)PA required
Humana Part D (CMS formulary file, plan-grounded).
tnf inhibitors(Humana)PA required
Humana Part D (CMS formulary file, plan-grounded).
tnf inhibitors(Cigna)PA required
Cigna Part D (CMS formulary file, plan-grounded).
jak inhibitors(Cigna)PA required
Cigna Part D (CMS formulary file, plan-grounded).
hepatitis c daa(Cigna)PA required
Cigna Part D (CMS formulary file, plan-grounded).
il inhibitors biologics(Cigna)PA required
Cigna Part D (CMS formulary file, plan-grounded).
tnf inhibitors(Aetna)PA required
Aetna Part D (CMS formulary file, plan-grounded).
jak inhibitors(Aetna)PA required
Aetna Part D (CMS formulary file, plan-grounded).
hepatitis c daa(Aetna)PA required
Aetna Part D (CMS formulary file, plan-grounded).
il inhibitors biologics(Aetna)PA required
Aetna Part D (CMS formulary file, plan-grounded).
jak inhibitors(Kaiser)PA required
Kaiser Part D (CMS formulary file, plan-grounded).
tnf inhibitors(Kaiser)PA required
Kaiser Part D (CMS formulary file, plan-grounded).
hepatitis c daa(Kaiser)PA required
Kaiser Part D (CMS formulary file, plan-grounded).
il inhibitors biologics(Kaiser)PA required
Kaiser Part D (CMS formulary file, plan-grounded).

commercial qhp

il inhibitors biologics(Molina Healthcare)PA required
Molina Healthcare commercial formulary. IL-1/IL-1Ra/IL-6/IL-5/anti-IgE and GI IL antagonists all PA
hepatitis c daa(Molina Healthcare)PA required
Molina Healthcare commercial formulary. Hep C agents and combinations carry PA
tnf inhibitors(Molina Healthcare)PA required
Molina Healthcare commercial formulary. Anti-TNF mAbs, soluble TNF receptor, and GI TNF blockers all carry PA
jak inhibitors(Molina Healthcare)PA required
Molina Healthcare commercial formulary. Antirheumatic JAK inhibitors carry PA (5 flags)

If denied in Washington

📨 Office of Administrative Hearings (OAH)

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Full criteria, sources & appeal paths — all 51 states.

You’ve seen the breadth and one state in full. The complete Gastroenterologypack — 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.