Farxiga 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.

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc.
California - Uniform Prior Authorization FormCalifornia
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc.
Cigna - General Medication Prior Authorization FormCigna Corporation
Colorado - Uniform Prior Authorization FormColorado

ICD-10 codes for Farxiga Prior Authorizations

N18.9Chronic kidney disease, unspecified
N18.5Chronic kidney disease, stage 5
N18.4Chronic kidney disease, stage 4 (severe)
N18.3Chronic kidney disease, stage 3 (moderate)
N18.2Chronic kidney disease, stage 2 (mild)
N18.1Chronic kidney disease, stage 1
I50Heart failure
I50.1Left ventricular failure, unspecified
I50.9Heart failure, unspecified
E11Type 2 diabetes mellitus
E11.9Type 2 diabetes mellitus without complications

Brand Resources

Formulary Look Up ToolFormulary Look Up Tool resource

Support for Getting Your Patient on Farxiga

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