Acthar 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

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 - 2026 Medicare Prior Authorization CriteriaBlue Cross Blue Shield of North Carolina · Updated May 10, 2026
Blue Cross Blue Shield of Tennessee - Medicare Part B Drug Prior Authorization PoliciesBlue Cross Blue Shield of Tennessee · Updated May 10, 2026
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated May 11, 2026
California - Uniform Prior Authorization FormCalifornia · Updated Apr 16, 2026
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc. · Updated May 11, 2026

ICD-10 codes for Acthar Prior Authorizations

G40.4Other generalized epilepsy and epileptic syndromes
G35Multiple sclerosis
L40.5Arthropathic psoriasis
M06Other rheumatoid arthritis
M45Ankylosing spondylitis
M32Systemic lupus erythematosus (SLE)
M33Dermatopolymyositis
L51Erythema multiforme
L51.1Stevens-Johnson syndrome
T80.6Other serum reactions
H16Keratitis
H20Iridocyclitis
H30Chorioretinal inflammation
H46Optic neuritis
D86Sarcoidosis
N04Nephrotic syndrome

Appeal Templates

If the payer denies coverage, these templates help you build a stronger appeal.
Patient Appeals Letter Template (Patient Initiated)Patient Appeals Letter Template (Patient Initiated) resource
Patient Appeal Discussion GuidePatient Appeal Discussion Guide resource
Patient Verbal Appeals TemplatePatient Verbal Appeals Template resource
Patient Appeals Letter Template (Patient Initiated) - SpanishPatient Appeals Letter Template (Patient Initiated) - Spanish resource
Patient Appeal Discussion Guide - SpanishPatient Appeal Discussion Guide - Spanish resource
Verbal Appeals Template - SpanishVerbal Appeals Template - Spanish resource
A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.

Support for Getting Your Patient on Acthar

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