Auth57 · Specialty PA Pack

Pulmonology

For the pulmonologist managing inhalers, biologics, and PAH — the PA and appeal map, all 51 states.

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Structured rules

1,954

PA-required

70%

Appeal layer

51/51

Criteria docs

50/51

The breadth · all 51 jurisdictions

Every state, quantified for pulmonology

State	Approved · CY25	Rules	PA-required	Appeal	Criteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing	88.2%	45	71%	✓	8
COColorado	91.8%	41	71%	✓	7
OHOhio	77.7%	45	73%	✓	14
All states · A–Z
AKAlaska	—	25	68%	✓	6
ALAlabama	—	40	70%	✓	8
ARArkansas	—	46	72%	✓	6
AZArizona	—	42	71%	✓	5
CACalifornia	—	45	69%	✓	6
CTConnecticut	—	40	70%	✓	4
DCDistrict of Columbia	—	40	70%	✓	9
DEDelaware	—	40	73%	✓	4
FLFlorida	—	41	71%	✓	2
GAGeorgia	—	46	67%	✓	15
HIHawaii	—	42	71%	✓	7
IAIowa	—	40	70%	✓	7
IDIdaho	—	29	69%	✓	8
ILIllinois	—	41	71%	✓	1
INIndiana	—	40	73%	✓	6
KSKansas	—	40	70%	✓	9
KYKentucky	—	44	70%	✓	4
LALouisiana	—	36	69%	✓	12
MAMassachusetts	—	34	71%	✓	6
MDMaryland	—	36	69%	✓	8
MEMaine	—	37	70%	✓	5
MIMichigan	—	37	73%	✓	16
MNMinnesota	—	30	70%	✓	2
MOMissouri	—	46	70%	✓	6
MSMississippi	—	43	70%	✓	8
MTMontana	—	29	69%	✓	3
NCNorth Carolina	—	46	74%	✓	23
NDNorth Dakota	—	28	64%	✓	3
NENebraska	—	38	71%	✓	4
NHNew Hampshire	—	37	70%	✓	—
NJNew Jersey	—	38	66%	✓	4
NMNew Mexico	—	30	67%	✓	3
NVNevada	—	36	69%	✓	19
NYNew York	—	42	71%	✓	9
OKOklahoma	—	45	69%	✓	3
OROregon	—	44	73%	✓	4
PAPennsylvania	—	37	70%	✓	12
RIRhode Island	—	29	69%	✓	1
SCSouth Carolina	—	40	73%	✓	8
SDSouth Dakota	—	26	65%	✓	4
TNTennessee	—	41	71%	✓	1
TXTexas	—	45	71%	✓	48
UTUtah	—	42	71%	✓	11
VAVirginia	—	44	70%	✓	6
VTVermont	—	25	68%	✓	13
WIWisconsin	—	40	73%	✓	2
WVWest Virginia	—	33	73%	✓	2
WYWyoming	—	28	68%	✓	8

Deep dive· Washington

Washington — pulmonology, 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%

asthma copd biologicsPA required
WA Medicaid PDL: non-preferred agents in this class require PA.
inhaled respiratoryPA required
WA Medicaid PDL: non-preferred agents in this class require PA.
pulmonary arterial hypertensionPA required
WA Medicaid PDL: non-preferred agents in this class require PA.

commercial regulated

pulmonary arterial hypertension(UnitedHealthcare)PA required
UnitedHealthcare commercial (Advantage 3-Tier). Respiratory-pulmonary hypertension; all carry PA+QL+SP (TYVASO PA+SP) [e.g. ADEMPAS, OPSUMIT, TYVASO, TADLIQ]
inhaled respiratory(UnitedHealthcare)PA required
UnitedHealthcare commercial (Advantage 3-Tier). Respiratory-asthma and COPD; inhalers QL/RS, but biologics in this heading (FASENRA, NUCALA, TEZSPIRE, XOLAIR PA+QL+SP) and YUPELRI carry PA [e.g. albuterol, BREO ELLIPTA, SYMBICORT, TRELEGY ELLIPTA]
asthma copd biologics(UnitedHealthcare)PA required
UnitedHealthcare commercial (Advantage 3-Tier). Asthma/COPD biologic subset within asthma/COPD heading; all carry PA+QL+SP [e.g. FASENRA, NUCALA, TEZSPIRE, XOLAIR]
leukotriene modifiers(UnitedHealthcare)No PA
UnitedHealthcare commercial (Advantage 3-Tier). Leukotriene modifier subset within asthma/COPD heading; tier 1-2, QL/none, no PA [e.g. montelukast, zafirlukast]
inhaled respiratory(Cigna)No PA
Cigna commercial (Advantage 3-Tier). inhalers/montelukast largely open (QL); BRONCHITOL=PA outlier [e.g. albuterol, ADVAIR HFA, BREO ELLIPTA, SPIRIVA RESPIMAT]
asthma copd biologics(Cigna)PA required
Cigna commercial (Advantage 3-Tier). respiratory biologics carry SP+PA [e.g. FASENRA PEN, NUCALA, TEZSPIRE, XOLAIR]
pulmonary arterial hypertension(Cigna)PA required
Cigna commercial (Advantage 3-Tier). PAH agents in respiratory section, SP+PA [e.g. ADEMPAS, OPSUMIT, TRACLEER, TYVASO]
pulmonary arterial hypertension(Aetna (CVS Caremark))PA required
Aetna (CVS Caremark) commercial formulary. specialty PAH, PA standard [e.g. sildenafil (PAH), tadalafil (PAH), ambrisentan, bosentan]
leukotriene modifiers(Aetna (CVS Caremark))No PA
Aetna (CVS Caremark) commercial formulary. leukotriene receptor antagonists, open generics [e.g. montelukast, zafirlukast, zileuton]
asthma copd biologics(Aetna (CVS Caremark))PA required
Aetna (CVS Caremark) commercial formulary. severe asthma biologics, specialty PA [e.g. omalizumab (XOLAIR), mepolizumab (NUCALA), benralizumab (FASENRA), dupilumab]
inhaled respiratory(Aetna (CVS Caremark))No PA
Aetna (CVS Caremark) commercial formulary. anticholinergic/beta-agonist/steroid inhalers (SABA/LABA/ICS/LAMA combos), brand-dominant; ST/preferred-product [e.g. albuterol, budesonide-formoterol, tiotropium, fluticasone]
inhaled respiratory(Anthem Blue Cross (Elevance))No PA
Anthem Blue Cross (Elevance) commercial formulary. Beta-adrenergics, inhaled steroids, anticholinergics, adrenergic combos: QL only, open [e.g. albuterol, budesonide-formoterol, ipratropium, mometasone inhaler]
leukotriene modifiers(Anthem Blue Cross (Elevance))No PA
Anthem Blue Cross (Elevance) commercial formulary. Leukotriene receptor antagonists: QL only, open [e.g. montelukast, zafirlukast]
pulmonary arterial hypertension(Anthem Blue Cross (Elevance))PA required
Anthem Blue Cross (Elevance) commercial formulary. Prostaglandin vasodilators, endothelin receptor antagonists, PDE5, sGC stimulators: PA + SP [e.g. treprostinil, ambrisentan, tadalafil (ALYQ), ADEMPAS riociguat]

part d

pulmonary arterial hypertension(Centene)PA required
Centene Part D (CMS formulary file, plan-grounded).
leukotriene modifiers(Centene)No PA
Centene Part D (CMS formulary file, plan-grounded).
inhaled respiratory(Centene)PA required
Centene Part D (CMS formulary file, plan-grounded).
asthma copd biologics(Centene)PA required
Centene Part D (CMS formulary file, plan-grounded).
pulmonary arterial hypertension(Unitedhealthcare)PA required
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
inhaled respiratory(Unitedhealthcare)PA required
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
asthma copd biologics(Unitedhealthcare)PA required
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
leukotriene modifiers(Unitedhealthcare)No PA
Unitedhealthcare Part D (CMS formulary file, plan-grounded).
inhaled respiratory(Humana)PA required
Humana Part D (CMS formulary file, plan-grounded).
asthma copd biologics(Humana)PA required
Humana Part D (CMS formulary file, plan-grounded).
pulmonary arterial hypertension(Humana)PA required
Humana Part D (CMS formulary file, plan-grounded).
leukotriene modifiers(Humana)No PA
Humana Part D (CMS formulary file, plan-grounded).
pulmonary arterial hypertension(Cigna)PA required
Cigna Part D (CMS formulary file, plan-grounded).
asthma copd biologics(Cigna)PA required
Cigna Part D (CMS formulary file, plan-grounded).
inhaled respiratory(Cigna)PA required
Cigna Part D (CMS formulary file, plan-grounded).
leukotriene modifiers(Cigna)No PA
Cigna Part D (CMS formulary file, plan-grounded).
asthma copd biologics(Aetna)PA required
Aetna Part D (CMS formulary file, plan-grounded).
inhaled respiratory(Aetna)PA required
Aetna Part D (CMS formulary file, plan-grounded).
pulmonary arterial hypertension(Aetna)PA required
Aetna Part D (CMS formulary file, plan-grounded).
leukotriene modifiers(Aetna)No PA
Aetna Part D (CMS formulary file, plan-grounded).
pulmonary arterial hypertension(Kaiser)PA required
Kaiser Part D (CMS formulary file, plan-grounded).
asthma copd biologics(Kaiser)PA required
Kaiser Part D (CMS formulary file, plan-grounded).
inhaled respiratory(Kaiser)PA required
Kaiser Part D (CMS formulary file, plan-grounded).
leukotriene modifiers(Kaiser)No PA
Kaiser Part D (CMS formulary file, plan-grounded).

commercial qhp

asthma copd biologics(Molina Healthcare)PA required
Molina Healthcare commercial formulary. Anti-IgE and IL-5 antagonist respiratory biologics carry PA
inhaled respiratory(Molina Healthcare)PA required
Molina Healthcare commercial formulary. Beta-adrenergic inhalers carry 2 ST; steroid inhalants and combos open
pulmonary arterial hypertension(Molina Healthcare)PA required
Molina Healthcare commercial formulary. Prostaglandin vasodilators / PAH agents carry 14 PA
leukotriene modifiers(Molina Healthcare)No PA
Molina Healthcare commercial formulary. montelukast/zafirlukast QL only, no PA/ST

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 Pulmonologypack — 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.