Glyxambi 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.

Amerigroup - NJ Medicaid Pharmacy Prior Authorization FormAmerigroup
Amerigroup - DC Medicaid Pharmacy Prior Authorization FormAmerigroup
Amerigroup Iowa - Anti-Diabetic Non-Insulin Agents Prior AuthorizationAmerigroup
Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield
Blue Cross Blue Shield of North Carolina - SGLT2 Inhibitors and Combinations Prior Authorization FormBlue Cross Blue Shield of North Carolina
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc.

ICD-10 codes for Glyxambi Prior Authorizations

E11.9Type 2 diabetes mellitus without complications
E11.65Type 2 diabetes mellitus with hyperglycemia
I25.9Chronic ischemic heart disease, unspecified
I99Other and unspecified disorders of the circulatory system

Brand Resources

Formulary InformationFormulary Information resource

Support for Getting Your Patient on Glyxambi

Check coverage & formulary statusVerify PA requirements for your patient's plan.Find savings programsCopay cards, patient assistance, and more.Check medication interactionsScreen prescriptions for harmful drug combinations.