Briviact 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.

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc.
Blue Cross of Idaho - Commercial Prior AuthorizationBlue Cross of Idaho Health Services, Inc.
California - Uniform Prior Authorization FormCalifornia
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc.
CarelonRx - Carelonrx Member AuthorizationCarelonRx

ICD-10 codes for Briviact Prior Authorizations

G40.001Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus
G40.009Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus
G40.101Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus
G40.109Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus
G40.201Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus
G40.209Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus

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