Lorbrena 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

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
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc. · Updated May 11, 2026
Cigna - General Medication Prior Authorization FormCigna Corporation · Updated May 11, 2026
Colorado - Uniform Prior Authorization FormColorado · Updated May 16, 2026

ICD-10 codes for Lorbrena Prior Authorizations

C34.90Malignant neoplasm of unspecified part of unspecified bronchus or lung

Appeal Templates

If the payer denies coverage, these templates help you build a stronger appeal.
Pfizer Sample Letter of Medical Necessity TemplateTemplate letter for HCPs to document medical necessity for Pfizer oncology drugs including Lorbrena
Pfizer Sample Formulary Exception Request LetterTemplate letter for requesting formulary exceptions when Lorbrena is not covered by insurance
Pfizer Sample Appeals Letter TemplateTemplate for appealing denied insurance claims for Pfizer oncology drugs including Lorbrena
Appeals ChecklistAppeals Checklist resource
Letter of Medical Necessity ChecklistLetter of Medical Necessity Checklist resource
A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.

Brand Resources

UnitedHealthcare Lorbrena Prior Authorization FormUnitedHealthcare prior authorization notification form with 12-month approval criteria for Lorbrena
Cigna Lorbrena Prior Authorization PolicyCigna coverage policy and prior authorization criteria for Lorbrena (lorlatinib) oncology treatment
UnitedHealthcare Lorbrena Step Therapy PolicyUnitedHealthcare step therapy requirements and guidelines for Lorbrena (lorlatinib) prescribing
Pharmacy ListPharmacy List resource
Field Reimbursement ManagerField Reimbursement Manager resource
PA Checklist PA Checklist resource

Support for Getting Your Patient on Lorbrena

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.