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Aciphex 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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Alliant Health Plans

Last verified: Apr 15, 2026Alliant Health Plans - Alliant Health Step Therapy Prior Authorization Request

Amerigroup

Last verified: Apr 15, 2026Amerigroup - Texas Medicaid Prior Authorization Requirements

Anthem, Inc.

Last verified: Apr 15, 2026Anthem, Inc. - Texas Medicare-Medicaid Plan Precertification 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 North Carolina

Last verified: Apr 15, 2026Blue Cross Blue Shield of North Carolina - Drug Determination Blue Medicare Prior Authorization Exception Request

Blue Cross of Idaho Health Services, Inc.

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

CareFirst, Inc.

Last verified: Apr 15, 2026CareFirst BlueCross BlueShield - Carefirst Prior Authorization Form Hyperinflation Non-Covered Drugs

CareSource Management Group

Last verified: Apr 15, 2026CareSource Management Group - Ohio Provider Medical Prior Authorization Request 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

ForwardHealth Wisconsin Medicaid

Last verified: Apr 15, 2026ForwardHealth Wisconsin Medicaid - ForwardHealth Prior Authorization Preferred Drug List for Proton Pump Inhibitor PPI Capsules and Tablets

Last verified: Apr 15, 2026ForwardHealth Wisconsin Medicaid - ForwardHealth Prior Authorization Preferred Drug List for Proton Pump Inhibitor PPI Capsules Suspensions and Non-ODT

Health Partners Plans

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

Humana, Inc.

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

Illinois

Last verified: Apr 16, 2026Illinois - Uniform 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

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

Louisiana

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

Maryland Physicians Care (MPC)

Last verified: Apr 15, 2026Maryland Physicians Care (MPC) - PPI Quantity Limit Prior Authorization Request

MC-RX

Last verified: Apr 15, 2026MC-RX - PPIs Prior Authorization Form

Medical Mutual of Ohio Corporation

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

MedImpact

Last verified: Apr 15, 2026MedImpact - Colorado Uniform Pharmacy Prior Authorization Request Form

Last verified: Apr 15, 2026MedImpact - Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

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 15, 2026Molina Health Care, Inc. - Proton Pump Inhibitors 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

National Association of Letter Carriers

Last verified: Apr 15, 2026National Association of Letter Carriers - Medications Pre-Authorization Requirements

Neighborhood Health Plan of Rhode Island

Last verified: Apr 15, 2026Neighborhood Health Plan of Rhode Island - Quantity Limit Exception Prior Authorization Form

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 - Choice Quantity Limit Prior Authorization Request

Providence Health System

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

State of Alaska

Last verified: Apr 15, 2026State of Alaska - AlaskaCare Pharmacy Prior Authorization

State of Connecticut

Last verified: Apr 15, 2026State of Connecticut - Pharmacy Step Therapy PA Form PPI

State of Pennsylvania

Last verified: Apr 15, 2026State of Pennsylvania - Proton Pump Inhibitors Prior Authorization Form

Texas

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

UnitedHealth Group, Inc.

Last verified: Apr 15, 2026UnitedHealthcare - UHC Commercial Advance Notification Prior Authorization Requirements 2025

Last verified: Apr 15, 2026UnitedHealthcare - Colorado Commercial Prescription Prior Authorization Request Form

Last verified: Apr 15, 2026UnitedHealthcare - Individual Exchange Pharmacy Prior Authorization and Exceptions

US Family Health Plan

Last verified: Apr 15, 2026US Family Health Plan - PPI Nexium Aciphex Prior Authorization Request

Washington

Last verified: Apr 16, 2026Washington - Uniform 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