Sign In
Home
Austedo xr
Prior Authorization Forms
Last verified:
Austedo XR Prior Authorization Resources
Get the latest prior authorization forms for Medicare, Medicaid, and commercial plans, as well as state and medication-specific forms.
Brand Resources
Reimbursement Information
Reimbursement Information resource
Formulary Information: Tardive Dyskinesia
Formulary Information: Tardive Dyskinesia resource
Formulary Information: Huntingdon's Disease Chorea
Formulary Information: Huntingdon's Disease Chorea resource
Coverage Authorization Appeals
Coverage Authorization Appeals resource
Letter of Medical Necessity
Letter of Medical Necessity resource
Austedo Prescription & Service Request Form For Twice-Daily Dosing
Austedo Prescription & Service Request Form For Twice-Daily Dosing resource
Austedo (XR) Prescription & Service Request Form For Once-Daily Dosing
Austedo (XR) Prescription & Service Request Form For Once-Daily Dosing resource
See approval requirements for your carrier
Find out what types of documentation and step therapies this carrier may require for coverage.
Check coverage
Prior Authorization Forms
Sort by
A-Z
California
Last verified: Dec 30, 2025
California - Uniform Prior Authorization Form
Download
Cigna Corporation
Last verified: Dec 19, 2025
Cigna - Austedo Prior Authorization Form
Download
Colorado
Last verified: Dec 30, 2025
Colorado - Uniform Prior Authorization Form
Download
Illinois
Last verified: Dec 30, 2025
Illinois - Uniform Prior Authorization Form
Download
Indiana
Last verified: Dec 30, 2025
Indiana - Uniform Prior Authorization Form
Download
Louisiana
Last verified: Dec 30, 2025
Louisiana - Uniform Prior Authorization Form
Download
Minnesota
Last verified: Dec 30, 2025
Minnesota - Uniform Prior Authorization Form
Download
Oregon
Last verified: Dec 30, 2025
Oregon - Uniform Prior Authorization Form
Download
Texas
Last verified: Dec 30, 2025
Texas - Uniform Prior Authorization Form
Download
Washington
Last verified: Dec 30, 2025
Washington - Uniform Prior Authorization Form
Download
Wisconsin
Last verified: Dec 30, 2025
Wisconsin - Uniform Prior Authorization Form
Download
See approval requirements for your carrier
Find out what types of documentation and step therapies this carrier may require for coverage.
Check coverage