Aciphex Prior Authorization Resources

Find the right PA form for your patient's payer, get the ICD-10 codes you need, and download appeal templates — all in one place.

Last verified: May 11, 2026

Alliant Health Plans - Alliant Health Step Therapy Prior Authorization RequestAlliant Health Plans · Updated Apr 15, 2026

Amerigroup - Texas Medicaid Prior Authorization RequirementsAmerigroup · Updated Apr 15, 2026

Anthem, Inc. - Texas Medicare-Medicaid Plan Precertification FormAnthem, Inc. · Updated Apr 24, 2026

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated May 11, 2026

Blue Cross Blue Shield of North Carolina - Drug Determination Blue Medicare Prior Authorization Exception RequestBlue Cross Blue Shield of North Carolina · Updated Apr 15, 2026

Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated May 11, 2026

ICD-10 codes for Aciphex Prior Authorizations

K21.0Gastro-esophageal reflux disease with esophagitis

K21.9Gastro-esophageal reflux disease without esophagitis

K26.0Acute duodenal ulcer with hemorrhage

K26.9Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation

B96.81Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere

E16.4Increased secretion of gastrin

Support for Getting Your Patient on Aciphex

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