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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.

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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 ↗
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

    WA Medicaid PDL: non-preferred agents in this class require PA.

  • opioid use disorderPA required

    WA Medicaid PDL: non-preferred agents in this class require PA.

commercial regulated
  • opioid use disorder(UnitedHealthcare)No PA

    UnitedHealthcare commercial (Advantage 3-Tier). Anti-addiction/substance abuse; QL only, no PA/ST [e.g. buprenorphine-naloxone, ZUBSOLV, naltrexone, NARCAN]

  • nsaids(UnitedHealthcare)No PA

    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]

  • opioid analgesics(UnitedHealthcare)PA required

    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]

  • skeletal muscle relaxants(UnitedHealthcare)PA required

    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]

  • nsaids(Cigna)No PA

    Cigna commercial (Advantage 3-Tier). oral NSAIDs open (QL); topical FLECTOR/LICART=PA [e.g. meloxicam, celecoxib, diclofenac, naproxen]

  • skeletal muscle relaxants(Cigna)No PA

    Cigna commercial (Advantage 3-Tier). muscle relaxants in pain section, open [e.g. cyclobenzaprine, tizanidine]

  • opioid use disorder(Cigna)No PA

    Cigna commercial (Advantage 3-Tier). MOUD/naloxone open, QL only [e.g. buprenorphine-naloxone, naltrexone, NARCAN, ZUBSOLV]

  • opioid analgesics(Cigna)PA required

    Cigna commercial (Advantage 3-Tier). opioids broadly carry PA [e.g. oxycodone ir, morphine er, hydrocodone-acetaminophen, NUCYNTA]

  • nsaids(Aetna (CVS Caremark))No PA

    Aetna (CVS Caremark) commercial formulary. COX-2 + NSAIDs, mostly open generics; brands NF [e.g. celecoxib, diclofenac, etodolac, meloxicam]

  • opioid analgesics(Aetna (CVS Caremark))PA required

    Aetna (CVS Caremark) commercial formulary. opioids carry QL/ST per CMS opioid safety edits [e.g. morphine, oxycodone, fentanyl, hydromorphone]

  • opioid use disorder(Aetna (CVS Caremark))PA required

    Aetna (CVS Caremark) commercial formulary. opioid agonist/antagonist + antagonist; MOUD, some PA/QL [e.g. buprenorphine-naloxone (SUBOXONE), naltrexone, naloxone]

  • opioid use disorder(Anthem Blue Cross (Elevance))No PA

    Anthem Blue Cross (Elevance) commercial formulary. Opioid partial agonists (buprenorphine): QL only, no PA in this listing [e.g. BRIXADI buprenorphine, buprenorphine sublingual]

  • nsaids(Anthem Blue Cross (Elevance))No PA

    Anthem Blue Cross (Elevance) commercial formulary. NSAIDs and COX-2: QL/ST only, no PA; open [e.g. diclofenac, ibuprofen, naproxen, celecoxib]

  • opioid analgesics(Anthem Blue Cross (Elevance))PA required

    Anthem Blue Cross (Elevance) commercial formulary. Opioid agonists/combinations carry PA + QL [e.g. hydrocodone-acetaminophen, oxycodone-acetaminophen, codeine combinations, tramadol-acetaminophen]

  • skeletal muscle relaxants(Anthem Blue Cross (Elevance))No PA

    Anthem Blue Cross (Elevance) commercial formulary. Central + direct muscle relaxants: QL only, open [e.g. baclofen, cyclobenzaprine, tizanidine, dantrolene]

part d
  • opioid use disorder(Centene)PA required

    Centene Part D (CMS formulary file, plan-grounded).

  • opioid analgesics(Centene)PA required

    Centene Part D (CMS formulary file, plan-grounded).

  • nsaids(Centene)No PA

    Centene Part D (CMS formulary file, plan-grounded).

  • skeletal muscle relaxants(Centene)PA required

    Centene Part D (CMS formulary file, plan-grounded).

  • nsaids(Unitedhealthcare)PA required

    Unitedhealthcare Part D (CMS formulary file, plan-grounded).

  • opioid use disorder(Unitedhealthcare)No PA

    Unitedhealthcare Part D (CMS formulary file, plan-grounded).

  • opioid analgesics(Unitedhealthcare)No PA

    Unitedhealthcare Part D (CMS formulary file, plan-grounded).

  • skeletal muscle relaxants(Unitedhealthcare)No PA

    Unitedhealthcare Part D (CMS formulary file, plan-grounded).

  • opioid use disorder(Humana)No PA

    Humana Part D (CMS formulary file, plan-grounded).

  • skeletal muscle relaxants(Humana)No PA

    Humana Part D (CMS formulary file, plan-grounded).

  • nsaids(Humana)PA required

    Humana Part D (CMS formulary file, plan-grounded).

  • opioid analgesics(Humana)PA required

    Humana Part D (CMS formulary file, plan-grounded).

  • nsaids(Cigna)PA required

    Cigna Part D (CMS formulary file, plan-grounded).

  • opioid use disorder(Cigna)No PA

    Cigna Part D (CMS formulary file, plan-grounded).

  • opioid analgesics(Cigna)No PA

    Cigna Part D (CMS formulary file, plan-grounded).

  • skeletal muscle relaxants(Cigna)PA required

    Cigna Part D (CMS formulary file, plan-grounded).

  • nsaids(Aetna)PA required

    Aetna Part D (CMS formulary file, plan-grounded).

  • opioid use disorder(Aetna)PA required

    Aetna Part D (CMS formulary file, plan-grounded).

  • opioid analgesics(Aetna)PA required

    Aetna Part D (CMS formulary file, plan-grounded).

  • skeletal muscle relaxants(Aetna)PA required

    Aetna Part D (CMS formulary file, plan-grounded).

  • opioid analgesics(Kaiser)No PA

    Kaiser Part D (CMS formulary file, plan-grounded).

  • opioid use disorder(Kaiser)PA required

    Kaiser Part D (CMS formulary file, plan-grounded).

  • nsaids(Kaiser)No PA

    Kaiser Part D (CMS formulary file, plan-grounded).

  • skeletal muscle relaxants(Kaiser)PA required

    Kaiser Part D (CMS formulary file, plan-grounded).

commercial qhp
  • opioid analgesics(Molina Healthcare)PA required

    Molina Healthcare commercial formulary. Opioid agonists carry 11 PA; combos open (QL only)

  • opioid use disorder(Molina Healthcare)PA required

    Molina Healthcare commercial formulary. Opioid partial agonists (buprenorphine) carry 2 PA; antagonists open

  • nsaids(Molina Healthcare)PA required

    Molina Healthcare commercial formulary. meclofenamate/mefenamic/fenoprofen carry PA; common NSAIDs open

  • skeletal muscle relaxants(Molina Healthcare)PA required

    Molina Healthcare commercial formulary. Central muscle relaxants carry 1 PA; direct/combos open

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.