REFERENCE ONLY — Based on publicly available payer policies. Formularies and PA criteria change frequently. Always verify current requirements directly with the payer before submission. Not a guarantee of coverage or payment. Some payers (e.g., Cigna) do not publish specific PA thresholds publicly — where exact criteria could not be confirmed from public sources, this has been noted. Payers intentionally keep criteria internal to retain flexibility and prevent gaming. Always verify directly with the payer before submission. © 2026 PARx Pilot LLC