Jaypirca - Pirtobrutinib tablet, Coated 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: Apr 24, 2026

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated Apr 24, 2026
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated Apr 24, 2026
California - Uniform Prior Authorization FormCalifornia · Updated Apr 16, 2026
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc. · Updated Apr 24, 2026
Caterpillar Prescription Drug Benefit - Prior Authorization Request FormCaterpillar Prescription Drug Benefit · Updated Apr 13, 2026
Cigna - General Medication Prior Authorization FormCigna Corporation · Updated Apr 24, 2026

ICD-10 codes for Jaypirca - Pirtobrutinib tablet, Coated Prior Authorizations

C83.19Mantle cell lymphoma, extranodal and solid organ sites
C91.10Chronic lymphocytic leukemia of B-cell type not having achieved remission
C82.90Follicular lymphoma, unspecified, unspecified site

Support for Getting Your Patient on Jaypirca - Pirtobrutinib tablet, Coated

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