Auth57 · Specialty PA Pack

Oncology

For the oncology team on oral chemo and supportive care — prior auth and appeals, mapped nationwide.

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Structured rules

907

PA-required

89%

Appeal layer

51/51

Criteria docs

51/51

The breadth · all 51 jurisdictions

Every state, quantified for oncology

State	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	19	89%	✓	13
COColorado	91.8%	18	89%	✓	2
OHOhio	77.7%	21	95%	✓	10
All states · A–Z
AKAlaska	—	14	86%	✓	6
ALAlabama	—	18	89%	✓	1
ARArkansas	—	19	89%	✓	7
AZArizona	—	19	89%	✓	6
CACalifornia	—	25	88%	✓	15
CTConnecticut	—	18	89%	✓	1
DCDistrict of Columbia	—	18	89%	✓	3
DEDelaware	—	18	89%	✓	4
FLFlorida	—	19	89%	✓	10
GAGeorgia	—	19	89%	✓	17
HIHawaii	—	19	89%	✓	14
IAIowa	—	18	89%	✓	8
IDIdaho	—	15	87%	✓	4
ILIllinois	—	18	89%	✓	9
INIndiana	—	18	89%	✓	8
KSKansas	—	18	89%	✓	9
KYKentucky	—	19	89%	✓	10
LALouisiana	—	17	88%	✓	13
MAMassachusetts	—	17	88%	✓	14
MDMaryland	—	17	88%	✓	8
MEMaine	—	17	88%	✓	4
MIMichigan	—	18	83%	✓	7
MNMinnesota	—	15	87%	✓	2
MOMissouri	—	20	90%	✓	4
MSMississippi	—	19	89%	✓	8
MTMontana	—	15	87%	✓	1
NCNorth Carolina	—	19	89%	✓	44
NDNorth Dakota	—	15	87%	✓	3
NENebraska	—	18	89%	✓	7
NHNew Hampshire	—	17	88%	✓	2
NJNew Jersey	—	17	88%	✓	5
NMNew Mexico	—	16	88%	✓	2
NVNevada	—	17	88%	✓	15
NYNew York	—	20	90%	✓	14
OKOklahoma	—	20	90%	✓	3
OROregon	—	19	89%	✓	5
PAPennsylvania	—	17	88%	✓	14
RIRhode Island	—	15	87%	✓	2
SCSouth Carolina	—	18	89%	✓	7
SDSouth Dakota	—	15	87%	✓	1
TNTennessee	—	18	89%	✓	9
TXTexas	—	21	86%	✓	80
UTUtah	—	18	89%	✓	5
VAVirginia	—	19	89%	✓	6
VTVermont	—	14	86%	✓	20
WIWisconsin	—	18	89%	✓	10
WVWest Virginia	—	16	88%	✓	4
WYWyoming	—	15	87%	✓	1

Deep dive· Washington

Washington — oncology, 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 mco

Approved · CMS-0057-F 202588.2%across 4 payers (81.2–93.1%)

Draft · aggregatedSource ↗

oncology oralPA required
diagnosisoncologist attestation

commercial regulated

oncology oral(UnitedHealthcare)PA requiredstep therapy
UnitedHealthcare commercial (Advantage 3-Tier). Antineoplastics-cancer; nearly all brand oral oncolytics carry PA+QL+SP; generics (anastrozole, tamoxifen) H-PA only [e.g. ALECENSA, CALQUENCE, LYNPARZA, TAGRISSO]
oncology oral(Cigna)PA requiredstep therapy
Cigna commercial (Advantage 3-Tier). oral oncolytics SP+PA throughout cancer section [e.g. IBRANCE, IMBRUVICA, VERZENIO, XTANDI]
oncology oral(Aetna (CVS Caremark))PA requiredstep therapy
Aetna (CVS Caremark) commercial formulary. oral antineoplastics (alkylating/antimetabolites/BCL-2/kinase/proteasome/topoisomerase), specialty PA [e.g. kinase inhibitors, VENCLEXTA, temozolomide, imatinib]
oncology supportive(Aetna (CVS Caremark))PA required
Aetna (CVS Caremark) commercial formulary. protective/supportive oncology agents [e.g. leucovorin, mesna, protective agents]
oncology oral(Anthem Blue Cross (Elevance))PA required
Anthem Blue Cross (Elevance) commercial formulary. Oral antineoplastics (ALK/BCR-ABL/BRAF/BTK/EGFR/MEK/mTOR/CDK/PARP/PI3K/multikinase/immunomodulators/antimetabolites/LHRH): PA + SP [e.g. capecitabine, IMBRUVICA ibrutinib, TAFINLAR dabrafenib, IBRANCE palbociclib]

dual eligible

oncology oralPA required
Part D primary. Part D protected class. Broad access required. LIS eliminates cost-sharing.

medicaid ffs

Approved · CMS-0057-F 202554.8%

oncology oralPA required
Diagnosis requiredOncologist attestation required

medicare advantage

oncology oralPA required
Part D protected class. Broad access required.

medicare traditional

oncology oralNo PA
Oral drugs under Part D PDP — no FFS Part B PA. IV/infused drugs Part B — no PA under FFS.

part d

oncology oralNo PA
FEDERAL PROTECTED CLASS. Broad access required.
oncology oral(Centene)PA required
Centene Part D (CMS formulary file, plan-grounded).
oncology oral(Unitedhealthcare)PA required
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
oncology oral(Humana)PA required
Humana Part D (CMS formulary file, plan-grounded).
oncology oral(Cigna)PA required
Cigna Part D (CMS formulary file, plan-grounded).
oncology oral(Aetna)PA required
Aetna Part D (CMS formulary file, plan-grounded).
oncology oral(Kaiser)PA required
Kaiser Part D (CMS formulary file, plan-grounded).

commercial qhp

oncology oral(Molina Healthcare)PA required
Molina Healthcare commercial formulary. Antineoplastics block: 86 PA flags across kinase inhibitors etc
oncology supportive(Molina Healthcare)PA required
Molina Healthcare commercial formulary. ESAs and TPO receptor agonists carry PA; 5-HT3 antiemetic 1 PA

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 Oncologypack — 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.