Prior Authorization Criteria by Drug: What Every Payer Actually Wants (2026)

Why Criteria Look Different But Are Really the Same

Every major payer publishes prior authorization criteria for its formulary drugs. UnitedHealthcare calls them "Prior Authorization Guidelines." Aetna calls them "Clinical Policy Bulletins." Cigna uses "Coverage Policies." Humana uses "Medical Coverage Policies." The naming varies — the structure is almost identical.

Every payer's criteria document answers four questions: Does this patient have the FDA-approved indication? Has the patient tried lower-cost alternatives first? Is there documentation of adequate trial and failure/intolerance? Does the patient lack contraindications?

Master those four categories and you can navigate any payer's criteria document.

The Universal Criteria Framework

Prior authorization criteria for specialty drugs follow a consistent pattern:

• ✓ Diagnostic criteria (ICD-10 codes, severity markers, biomarker testing)
• ✓ Step therapy requirements (prior agents tried, dose, duration, outcome)
• ✓ Documentation requirements (specialist evaluation, labs, imaging)
• ✓ Dosing constraints (FDA-approved dose, quantity limits)
• ✓ Ongoing response requirements (renewal criteria based on clinical improvement)

Criteria by Drug Class: Biologics

For TNF inhibitors (Humira, Enbrel, Remicade, Cimzia, Simponi), IL-17 inhibitors (Cosentyx, Taltz, Siliq, Bimzelx), and IL-23 inhibitors (Stelara, Tremfya, Skyrizi, Ilumya), expect:

• ✓ Conventional DMARD trial (methotrexate, leflunomide, sulfasalazine) for ≥3 months, OR documented contraindication
• ✓ For psoriasis: phototherapy trial AND one systemic therapy failure
• ✓ For IBD: corticosteroid AND immunomodulator failure
• ✓ TB screening (QuantiFERON or PPD) and hepatitis B screening before initiation
• ✓ Specialist evaluation (rheum, derm, or GI)
• ✓ Baseline disease activity documentation

Criteria by Drug Class: GLP-1s

For semaglutide (Ozempic, Wegovy, Rybelsus), tirzepatide (Mounjaro, Zepbound), liraglutide (Victoza, Saxenda), and dulaglutide (Trulicity):

• ✓ For T2DM indications: A1C within 3 months, metformin trial ≥3 months at maximum tolerated dose
• ✓ For obesity indications: BMI ≥30 OR ≥27 with weight-related comorbidity, documented 6-month lifestyle intervention
• ✓ Absence of personal/family history of medullary thyroid carcinoma or MEN2
• ✓ No pancreatitis history
• ✓ Endocrinologist or obesity specialist evaluation for some plans

Criteria by Drug Class: Oncology

For targeted therapies (kinase inhibitors, PARP inhibitors, CDK4/6 inhibitors) and immunotherapies (pembrolizumab, nivolumab, atezolizumab):

• ✓ Confirmed histopathologic diagnosis with pathology report
• ✓ Biomarker testing results: PD-L1 score, EGFR mutation, ALK rearrangement, BRCA status, HER2, MSI-H, etc.
• ✓ NCCN-compendium alignment for the line of therapy
• ✓ ECOG performance status
• ✓ Staging information
• ✓ Prescribing oncologist attestation

Criteria by Drug Class: CGRP Migraine Prevention

For erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), eptinezumab (Vyepti), rimegepant (Nurtec), atogepant (Qulipta):

• ✓ ≥4 migraine days per month (episodic) or ≥15 headache days per month (chronic)
• ✓ Failure or intolerance of ≥2 preventive medication classes (beta-blocker, tricyclic, topiramate, valproate, or onabotulinumtoxinA)
• ✓ Each prior trial ≥2 months at adequate dose
• ✓ Migraine headache diary for renewal (≥50% reduction in migraine days)

Criteria by Drug Class: Multiple Sclerosis DMTs

For fingolimod (Gilenya), ozanimod (Zeposia), dimethyl fumarate (Tecfidera), teriflunomide (Aubagio), ocrelizumab (Ocrevus), ofatumumab (Kesimpta):

• ✓ MRI-confirmed demyelinating disease consistent with MS
• ✓ MS phenotype specified (RRMS, SPMS, PPMS)
• ✓ JCV antibody status for natalizumab
• ✓ Neurologist-directed therapy selection
• ✓ Lab monitoring plan

How to Map Any Payer's Criteria to Your Chart

The fastest way to build a winning PA: open the payer's criteria document side-by-side with the patient's chart. For each criterion, copy it into your letter verbatim, then paste the matching chart evidence directly beneath. Reviewers love this format because it makes approval decisions mechanical.

Criteria that can't be met from the chart require additional documentation. Order the missing labs, schedule the specialist consult, or attach the prior records. Never submit a PA with unmet criteria hoping the reviewer will overlook them.

How RxCheckUp Automates Criteria Matching

RxCheckUp maintains current prior authorization criteria for 62 major payers across 571 drugs. When a clinician enters the patient's plan, drug, and diagnosis, the platform surfaces the exact criteria document, highlights each criterion, and asks the clinician to confirm or provide chart evidence for each one. The resulting LMN addresses every criterion in the payer's own language.