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Abilify Asimtufii Prior Authorization Resources

Get the latest prior authorization forms for Medicare, Medicaid, and commercial plans, as well as state and medication-specific forms.

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Prior Authorization Forms

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Amerigroup

Last verified: Apr 12, 2026Amerigroup - Texas State Standard Pharmacy Authorization Form

Last verified: Apr 10, 2026Amerigroup - Abilify Maintena Prior Authorization

AmeriHealth Caritas Community Health Choices Pennsylvania

Last verified: Apr 10, 2026AmeriHealth Caritas Community Health Choices Pennsylvania - Antipsychotics Prior Authorization Form

AmeriHealth Caritas DC

Last verified: Apr 10, 2026AmeriHealth Caritas DC - Atypical Antipsychotics Prior Authorization Form

AmeriHealth Caritas Pennsylvania

Last verified: Apr 10, 2026AmeriHealth Caritas Pennsylvania - Injectable Antipsychotics Prior Authorization Form

Arkansas Blue Cross Blue Shield

Last verified: Apr 15, 2026Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form

Blue Cross Blue Shield of Illinois

Last verified: Apr 10, 2026Blue Cross Blue Shield of Illinois - 2025 Commercial Prior Authorization Summary

Last verified: Apr 10, 2026Blue Cross Blue Shield of Illinois - 2025 Commercial Specialty Pharmacy PA Code List

Blue Cross Blue Shield of North Carolina

Last verified: Apr 10, 2026Blue Cross Blue Shield of North Carolina - Nonformulary Exception Request or Value Prior Authorization Faxback Form

Blue Cross of Idaho Health Services, Inc.

Last verified: Apr 15, 2026Blue Cross of Idaho - General Prior Authorization Form

Blue Shield of California

Last verified: Apr 12, 2026Blue Shield of California - Prescription Drug Prior Authorization or Step Therapy Exception Request Form

California

Last verified: Apr 16, 2026California - Uniform Prior Authorization Form

Capital District Physicians Health Plan, Inc.

Last verified: Apr 15, 2026CDPHP - General Prior Authorization Form

Cigna Corporation

Last verified: Apr 15, 2026Cigna - General Medication Prior Authorization Form

Colorado

Last verified: Apr 16, 2026Colorado - Uniform Prior Authorization Form

Curative Health Insurance

Last verified: Apr 15, 2026Curative Health Insurance - Prior Authorization Form

CVS Caremark

Last verified: Apr 15, 2026Caremark - Formulary Exception and Prior Authorization Form

CVS Health (Aetna)

Last verified: Apr 15, 2026Aetna - Illinois Prior Authorization Request Form

Last verified: Apr 15, 2026Aetna - Medicare Prescription Drug Coverage Determination

Last verified: Apr 15, 2026Aetna - Arizona Prior Authorization Form

Last verified: Apr 15, 2026Aetna - Oregon Prior Authorization/Medical Exception/Precertification Form

Last verified: Apr 15, 2026Aetna - Louisiania Prior Authorization Request Form

Last verified: Apr 15, 2026Aetna - Medical Exception/Prior Authorization/Precertification Request for Prescription Medications

Last verified: Apr 15, 2026Aetna - Iowa Prior Authorization/Medical Exception/Precertification Request Form

Last verified: Apr 15, 2026Aetna - California Prior Authorization Form

Last verified: Apr 15, 2026Aetna - Texas Prior Authorization Form

Last verified: Apr 15, 2026Aetna - New Hampshire Prior Authorization Form

Department of Veterans Affairs (VHA)

Last verified: Apr 10, 2026Department of Veterans Affairs (VHA) - Long Acting Injectable Antipsychotics Aripiprazole Abilify Asimtufii Criteria for Use

Health Partners Plans

Last verified: Apr 15, 2026Health Partners - General Prior Authorization Form

Humana, Inc.

Last verified: Apr 15, 2026Humana - General Prior Authorization Form

Independent Health Association, Inc.

Last verified: Apr 15, 2026Independence Health - Premium Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Select Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Value Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Medicare Part D Pharmacy Prior Authorization Form

Indian Health Service (IHS)

Last verified: Apr 10, 2026Indian Health Service (IHS) - NPTC Formulary Brief Long Acting Injectable Antipsychotics

Indiana

Last verified: Apr 16, 2026Indiana - Uniform Prior Authorization Form

Kaiser Foundation Health Plans, Inc.

Last verified: Apr 15, 2026Kaiser Permanente of Colorado - Medicare Medication Request form (MRF)

Last verified: Apr 15, 2026Kaiser Permanente of Colorado HMO - Uniform Pharmacy Prior Authorization Request Form

Kansas Medicaid

Last verified: Apr 10, 2026Kansas Medicaid - Antipsychotic Prior Authorization Form

Keystone First

Last verified: Apr 10, 2026Keystone First - Injectable Antipsychotics Prior Authorization Form

Louisiana

Last verified: Apr 16, 2026Louisiana - Uniform Prior Authorization Form

Medical Mutual of Ohio Corporation

Last verified: Apr 15, 2026Medical Mutual of Ohio - General Prior Authorization Form

Minnesota

Last verified: Apr 16, 2026Minnesota - Uniform Prior Authorization Form

Molina Health Care, Inc.

Last verified: Apr 15, 2026Molina - Ohio Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Mississippi Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina- Utah Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - Utah Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Idaho Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - California Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - Idaho Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Wisconsin Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Kentucky Pharmacy Prior Authorization Form

Last verified: Apr 14, 2026Molina Health Care - Texas Medicaid CHIP Prior Authorization Criteria Guide

Last verified: Apr 12, 2026Molina Health Care - Michigan Medicaid and Marketplace Drug Prior Authorization Form

MVP Health Care, Inc.

Last verified: Apr 15, 2026MVP Health Care - NYS Medicaid Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026MVP Health Care - Pharmacy Prior Authorization Form

Neighborhood Health Plan of Rhode Island

Last verified: Apr 10, 2026Neighborhood Health Plan of Rhode Island - Medicaid Aripiprazole Injection

Oregon

Last verified: Apr 16, 2026Oregon - Uniform Prior Authorization Form

PacificSource Health Plan

Last verified: Apr 15, 2026Pacific Source - Medicaid Community Solutions Prior Authorization Form

Last verified: Apr 15, 2026Pacific Source - Pharmacy Prior Authorization Form

Premera, Inc.

Last verified: Apr 15, 2026Premera - Pharmacy Prior Authorization Form

Prime Therapeutics

Last verified: Apr 15, 2026Prime Therapeutics - Michigan Medicaid Prescription Drug General Prior Authorization Form

Providence Health System

Last verified: Apr 15, 2026Providence Health Plan - Drug Prior Authorization Form

SelectHealth

Last verified: Apr 10, 2026SelectHealth - RxFlex Prior Authorization 2026

Sierra Health and Life

Last verified: Apr 10, 2026Sierra Health and Life - LAI Process

State of Illinois

Last verified: Apr 10, 2026State of Illinois - Long Acting Injectable Atypical Antipsychotics Prior Authorization Request Form

Last verified: Apr 16, 2026Illinois - Uniform Prior Authorization Form

State of Maryland

Last verified: Apr 10, 2026State of Maryland - Antipsychotic Prior Authorization Form

State of Massachusetts

Last verified: Apr 10, 2026State of Massachusetts - Long-Acting Injectable Antipsychotic Medications Administered in Inpatient Psychiatry Units

State of Michigan

Last verified: Apr 10, 2026State of Michigan - MHP Common Formulary PDL Prior Authorization Criteria

State of North Dakota

Last verified: Apr 10, 2026State of North Dakota - Concurrent Antipsychotics PA Form

State of Tennessee

Last verified: Apr 10, 2026State of Tennessee - Atypical Antipsychotic Prior Authorization Form

Texas

Last verified: Apr 16, 2026Texas - Uniform Prior Authorization Form

Washington

Last verified: Apr 16, 2026Washington - Uniform Prior Authorization Form

Wellpoint Washington Medicaid

Last verified: Apr 12, 2026Wellpoint Washington Medicaid - Washington Wellpoint Medicaid Pharmacy Prior Authorization Form

Wisconsin

Last verified: Apr 16, 2026Wisconsin - Uniform Prior Authorization Form

See approval requirements for your carrier

Find out what types of documentation and step therapies this carrier may require for coverage.

Check coverage