Hetlioz 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

Amerigroup - Iowa Medicaid Prior Authorization RequestAmerigroup · Updated May 10, 2026

AmeriHealth Caritas North Carolina - Pharmacy Prior Authorization RequestAmeriHealth Caritas North Carolina · Updated May 10, 2026

Anthem Indiana Medicaid - Indiana Medicaid Prior Authorization RequestAnthem Indiana Medicaid · Updated May 10, 2026

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated May 11, 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 May 16, 2026

ICD-10 codes for Hetlioz Prior Authorizations

G47.24Circadian rhythm sleep disorder, free running type

Q93.88Other microdeletions

Brand Resources

Pharmacy List (VA only)Pharmacy List (VA only) resource

Hetlioz Service Request Form - Department of Veterans Affairs (VA) ONLYHetlioz Service Request Form - Department of Veterans Affairs (VA) ONLY resource

Support for Getting Your Patient on Hetlioz

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.