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Rheumatology care
Auth57 · Specialty PA Pack

Rheumatology

For the rheumatologist whose patients live on biologics — every plan's PA rule and the appeal path, across all 51 states.

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Structured rules
1,426
PA-required
98%
Appeal layer
51/51
Criteria docs
43/51
The breadth · all 51 jurisdictions

Every state, quantified for rheumatology

StateApproved · CY25RulesPA-requiredAppealCriteria docs
● Recent · CY2025 disclosures — click a state to drill in
WAWashington▸ viewing88.2%32100%✓4
COColorado91.8%2990%✓8
OHOhio77.7%34100%✓14
All states · A–Z
AKAlaska—19100%✓3
ALAlabama—31100%✓6
ARArkansas—32100%✓3
AZArizona—29100%✓3
CACalifornia—3491%✓8
CTConnecticut—30100%✓2
DCDistrict of Columbia—3090%✓3
DEDelaware—28100%✓3
FLFlorida—31100%✓—
GAGeorgia—3391%✓2
HIHawaii—3184%✓3
IAIowa—28100%✓7
IDIdaho—22100%✓3
ILIllinois—29100%✓3
INIndiana—28100%✓1
KSKansas—30100%✓38
KYKentucky—33100%✓3
LALouisiana—27100%✓6
MAMassachusetts—25100%✓3
MDMaryland—2688%✓2
MEMaine—26100%✓2
MIMichigan—28100%✓5
MNMinnesota—22100%✓1
MOMissouri—36100%✓—
MSMississippi—33100%✓4
MTMontana—20100%✓1
NCNorth Carolina—33100%✓1
NDNorth Dakota—21100%✓—
NENebraska—26100%✓4
NHNew Hampshire—26100%✓—
NJNew Jersey—27100%✓3
NMNew Mexico—22100%✓—
NVNevada—26100%✓10
NYNew York—31100%✓12
OKOklahoma—34100%✓2
OROregon—3190%✓2
PAPennsylvania—28100%✓9
RIRhode Island—20100%✓—
SCSouth Carolina—29100%✓4
SDSouth Dakota—19100%✓—
TNTennessee—30100%✓3
TXTexas—34100%✓28
UTUtah—31100%✓24
VAVirginia—3291%✓3
VTVermont—18100%✓5
WIWisconsin—29100%✓1
WVWest Virginia—24100%✓—
WYWyoming—19100%✓3
Deep dive· Washington

Washington — rheumatology, 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.
  • jak inhibitorsPA required

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

commercial regulated
  • 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]

  • 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]

  • 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]

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).

  • 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).

  • 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).

  • 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).

  • 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).

  • 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).

  • 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

  • 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.

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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.