Doryx MPC 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.

Amerigroup - Topical Acne Rosacea Products Prior Authorization of Benefits FormAmerigroup
Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield
Blue Cross Blue Shield of Alabama - Medicare Part D Prescription Drug Authorization Request FormBlue Cross Blue Shield of Alabama
Blue Cross Blue Shield of Alabama - General Prescription Drug Coverage Authorization Request FormBlue Cross Blue Shield of Alabama
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc.
BlueCross BlueShield of Western New York - NYS Medicaid Prior Authorization Request Form for PrescriptionsBlueCross BlueShield of Western New York

ICD-10 codes for Doryx MPC Prior Authorizations

A77.0Spotted fever due to Rickettsia rickettsii
A75.9Typhus fever, unspecified
A78Q fever
A79.1Rickettsialpox due to Rickettsia akari
N34.1Nonspecific urethritis
A55Chlamydial lymphogranuloma (venereum)
A58Granuloma inguinale
A54.9Gonococcal infection, unspecified
A57Chancroid
A70Chlamydia psittaci infections
J06.9Acute upper respiratory infection, unspecified
A68Relapsing fevers
A20.9Plague, unspecified
A21Tularemia
A00Cholera
A23Brucellosis
A44Bartonellosis
A71Trachoma
A74.0Chlamydial conjunctivitis
A17.0Tuberculous meningitis
A51Early syphilis
A66Yaws
A32Listeriosis
A69.1Other Vincent's infections
A42Actinomycosis
A06Amebiasis
L70Acne
B50Plasmodium falciparum malaria
N34Urethritis and urethral syndrome
N72Inflammatory disease of cervix uteri
K62.8Other specified diseases of anus and rectum
N39.0Urinary tract infection, site not specified

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