Lacrisert 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 Lacrisert Prior Authorizations

H04.12Dry eye syndrome
H16.22Keratoconjunctivitis sicca, not specified as Sjögren's
H16.209Unspecified keratoconjunctivitis, unspecified eye
H18.819Anesthesia and hypoesthesia of cornea, unspecified eye
H18.009Unspecified corneal ulcer, unspecified eye

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