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.

Last verified: May 11, 2026

Amerigroup - NJ Medicaid Pharmacy Prior Authorization FormAmerigroup · Updated May 10, 2026
Amerigroup - DC Medicaid Pharmacy Prior Authorization FormAmerigroup · Updated May 10, 2026
Amerigroup Iowa - Anti-Diabetic Non-Insulin Agents Prior AuthorizationAmerigroup · 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 Blue Shield of North Carolina - SGLT2 Inhibitors and Combinations Prior Authorization FormBlue Cross Blue Shield of North Carolina · Updated May 10, 2026
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated May 11, 2026

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

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