Xembify 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
Cigna - Intravenous Immune Globulin (IVIG) -SCIG Prior Authorization Form Cigna Corporation · Updated May 11, 2026

ICD-10 codes for Xembify Prior Authorizations

D80Immunodeficiency with predominantly antibody defects
D80.0Hereditary hypogammaglobulinemia
D83.9Common variable immunodeficiency, unspecified
D82.0Wiskott-Aldrich syndrome
D81.0Severe combined immunodeficiency [SCID] with reticular dysgenesis
D81.1Severe combined immunodeficiency [SCID] with low T- and B-cell numbers
D81.2Severe combined immunodeficiency [SCID] with low or normal B-cell numbers
D81.8Other combined immunodeficiencies
D81.9Combined immunodeficiency, unspecified

Brand Resources

XEMBIFY Guide to Coverage and ReimbursementCoverage support and authorization resources. For healthcare professionals treating PIDD with XEMBIFY.
XEMBIFY Coverage Authorization LettersCoverage support and authorization resources. For healthcare professionals treating PIDD with XEMBIFY.

Support for Getting Your Patient on Xembify

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.