Ubrelvy 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 Ubrelvy Prior Authorizations

G43.0Migraine without aura
G43.1Migraine with aura
G43.9Migraine, unspecified

Brand Resources

Dual Branded Prior Authorization Guide for QULIPTA and UBRELVYGuide for prior authorization of Qulipta and Ubrelvy.
Ubrelvy Prescription FormUbrelvy prescription form for prior authorization.
PA GuidePA Guide resource

Support for Getting Your Patient on Ubrelvy

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.