Payer-specific criteria, step therapy requirements, and documentation checklists for the drugs and procedures most frequently denied. Updated from primary sources.
PA requirements for all major GLP-1 and dual GIP/GLP-1 drugs — Ozempic, Wegovy, Mounjaro, Zepbound, Rybelsus, Trulicity — across UnitedHealthcare, Aetna, BCBS, Cigna, Humana, and Medicare. Three separate PA pathways: Type 2 diabetes, weight management, and cardiovascular risk reduction.
Complete PA requirements for all FDA-approved CGRP drugs — Aimovig, Ajovy, Emgality, Vyepti, Nurtec, Qulipta, Ubrelvy — across UnitedHealthcare, Aetna, BCBS, Cigna, Humana, and Medicare. Step therapy criteria, diagnosis thresholds, and payer-specific variations.
Prior authorization for Auvelity (dextromethorphan/bupropion) for MDD — Cigna, UHC, Aetna, BCBS, and Medicare step-therapy counts, the bupropion-component documentation trap, and tips for first-pass approval.
Prior authorization for Cobenfy (xanomeline/trospium) for schizophrenia — Cigna, UHC, Aetna, BCBS, and Medicare step-therapy counts, the D2 step-therapy trap and how to argue around it, and tips for first-pass approval.
Prior authorization for Exxua (gepirone ER) for major depressive disorder — Cigna, UHC, Aetna, BCBS, Centene, and Medicare step-therapy counts, the SSRI/SNRI step-therapy mismatch argument, QTc documentation requirements, RxConnect dispensing, and tips for first-pass approval.
Prior authorization for deep TMS for OCD — Y-BOCS thresholds, SSRI failure criteria, ERP requirements, and payer-specific criteria across UnitedHealthcare, Cigna, BCBS, Humana, and Medicare. Includes the device distinction and why Aetna is a dead end.