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Rebyota Prior Authorization Resources

Get the latest prior authorization forms for Medicare, Medicaid, and commercial plans, as well as state and medication-specific forms.

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Prior Authorization Forms

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Arkansas Blue Cross Blue Shield

Last verified: Apr 15, 2026Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form

Blue Cross Blue Shield of Massachusetts

Last verified: Apr 10, 2026Blue Cross Blue Shield of Massachusetts - 682 Fecal Microbiota Transplantation

Last verified: Apr 09, 2026Blue Cross Blue Shield of Massachusetts - 682 Fecal Microbiota Transplantation

Blue Cross Blue Shield of Michigan

Last verified: Apr 10, 2026Blue Cross Blue Shield of Michigan - Alert 20230119 Rebyota Medicare Advantage Prior Authorization

Blue Cross of Idaho Health Services, Inc.

Last verified: Apr 15, 2026Blue Cross of Idaho - General Prior Authorization Form

Blue Shield of California

Last verified: Apr 10, 2026Blue Shield of California - 2.01.92 Fecal Microbiota Transplantation

California

Last verified: Apr 16, 2026California - Uniform Prior Authorization Form

Capital District Physicians Health Plan, Inc.

Last verified: Apr 15, 2026CDPHP - General Prior Authorization Form

Cigna Corporation

Last verified: Apr 15, 2026Cigna - General Medication Prior Authorization Form

Last verified: Apr 09, 2026Cigna - Rebyota Prior Authorization Form

Clover Health

Last verified: Apr 10, 2026Clover Health - Rebyota MedB CMS 5693-A Standard Medicare Part B Management

Colorado

Last verified: Apr 16, 2026Colorado - Uniform Prior Authorization Form

Curative Health Insurance

Last verified: Apr 15, 2026Curative Health Insurance - Prior Authorization Form

CVS Caremark

Last verified: Apr 15, 2026Caremark - Formulary Exception and Prior Authorization Form

CVS Health (Aetna)

Last verified: Apr 15, 2026Aetna - Illinois Prior Authorization Request Form

Last verified: Apr 15, 2026Aetna - Medicare Prescription Drug Coverage Determination

Last verified: Apr 15, 2026Aetna - Arizona Prior Authorization Form

Last verified: Apr 15, 2026Aetna - Oregon Prior Authorization/Medical Exception/Precertification Form

Last verified: Apr 15, 2026Aetna - Louisiania Prior Authorization Request Form

Last verified: Apr 15, 2026Aetna - Medical Exception/Prior Authorization/Precertification Request for Prescription Medications

Last verified: Apr 15, 2026Aetna - Iowa Prior Authorization/Medical Exception/Precertification Request Form

Last verified: Apr 15, 2026Aetna - California Prior Authorization Form

Last verified: Apr 15, 2026Aetna - Texas Prior Authorization Form

Last verified: Apr 15, 2026Aetna - New Hampshire Prior Authorization Form

Department of Veterans Affairs (VHA)

Last verified: Apr 09, 2026Department of Veterans Affairs (VHA) - Fecal Microbiota Products for Clostridioides Difficile Infections Clinical Determination and Indication

Last verified: Apr 09, 2026Department of Veterans Affairs (VHA) - Fecal Microbiota Live Rebyota Criteria for Use

Health Partners Plans

Last verified: Apr 15, 2026Health Partners - General Prior Authorization Form

Highmark Health Options

Last verified: Apr 10, 2026Highmark Health Options - HHO-DE-MP-1146 Fecal Microbiota Transplantation

Humana, Inc.

Last verified: Apr 15, 2026Humana - General Prior Authorization Form

Illinois

Last verified: Apr 16, 2026Illinois - Uniform Prior Authorization Form

Independent Health Association, Inc.

Last verified: Apr 15, 2026Independence Health - Premium Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Select Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Value Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Medicare Part D Pharmacy Prior Authorization Form

Indiana

Last verified: Apr 16, 2026Indiana - Uniform Prior Authorization Form

Kaiser Foundation Health Plans, Inc.

Last verified: Apr 15, 2026Kaiser Permanente of Colorado - Medicare Medication Request form (MRF)

Last verified: Apr 15, 2026Kaiser Permanente of Colorado HMO - Uniform Pharmacy Prior Authorization Request Form

Louisiana

Last verified: Apr 16, 2026Louisiana - Uniform Prior Authorization Form

Louisiana Healthcare Connections

Last verified: Apr 10, 2026Louisiana Healthcare Connections - LA.PHAR.613 Fecal Microbiota Live-jslm Rebyota

Medical Mutual of Ohio Corporation

Last verified: Apr 15, 2026Medical Mutual of Ohio - General Prior Authorization Form

Minnesota

Last verified: Apr 16, 2026Minnesota - Uniform Prior Authorization Form

Molina Health Care, Inc.

Last verified: Apr 15, 2026Molina - Ohio Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Mississippi Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina- Utah Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - Utah Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Idaho Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - California Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - Idaho Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Wisconsin Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Kentucky Pharmacy Prior Authorization Form

MVP Health Care, Inc.

Last verified: Apr 15, 2026MVP Health Care - NYS Medicaid Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026MVP Health Care - Pharmacy Prior Authorization Form

Oregon

Last verified: Apr 16, 2026Oregon - Uniform Prior Authorization Form

PacificSource Health Plan

Last verified: Apr 15, 2026Pacific Source - Medicaid Community Solutions Prior Authorization Form

Last verified: Apr 15, 2026Pacific Source - Pharmacy Prior Authorization Form

Premera, Inc.

Last verified: Apr 15, 2026Premera - Pharmacy Prior Authorization Form

Providence Health System

Last verified: Apr 15, 2026Providence Health Plan - Drug Prior Authorization Form

Last verified: Apr 10, 2026Providence Health Plan - 2023 Prior Authorization Criteria for Part B Drugs

State of South Dakota

Last verified: Apr 13, 2026South Dakota Medicaid - Fecal Microbiota Live Rectal Rebyota Form

Texas

Last verified: Apr 16, 2026Texas - Uniform Prior Authorization Form

UnitedHealth Group, Inc.

Last verified: Apr 09, 2026UnitedHealthcare - UHC Rebyota for Louisiana Only

Washington

Last verified: Apr 16, 2026Washington - Uniform Prior Authorization Form

Wisconsin

Last verified: Apr 16, 2026Wisconsin - Uniform Prior Authorization Form

See approval requirements for your carrier

Find out what types of documentation and step therapies this carrier may require for coverage.

Check coverage