Alrex 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 and Blue Shield of Kansas - Eysuvis (Loteprednol Etabonate) Prior Authorization with Quantity Limit Program SummaryBlue Cross and Blue Shield of Kansas · Updated May 09, 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 Apr 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

ICD-10 codes for Alrex Prior Authorizations

H10.0Acute atopic conjunctivitis
H10.01Acute atopic conjunctivitis, right eye
H10.02Acute atopic conjunctivitis, left eye
H10.03Acute atopic conjunctivitis, bilateral

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