Dextenza 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

Wellpoint Texas Medicaid - Texas Medicaid Prior Authorization Request FormAmerigroup · Updated May 10, 2026
Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated May 11, 2026
BlueCross BlueShield of Tennessee - Provider-Administered Medication Authorization FormBlue Cross Blue Shield of Tennessee · Updated May 10, 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

ICD-10 codes for Dextenza Prior Authorizations

H20.011Primary iridocyclitis, right eye
H20.012Primary iridocyclitis, left eye
H59.011Keratopathy (bullous aphakic) following cataract surgery, right eye
H10.10Acute atopic conjunctivitis, unspecified eye
H10.11Acute atopic conjunctivitis, right eye
H10.45Other chronic allergic conjunctivitis

Appeal Templates

If the payer denies coverage, these templates help you build a stronger appeal.
Coverage Authorization Appeals (Through OcuCare HCP Portal)Coverage Authorization Appeals (Through OcuCare HCP Portal) resource
A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.

Brand Resources

Reimbursement InformationReimbursement Information resource
Billing & Coding Guide Billing & Coding Guide resource
How To Order DextenzaHow To Order Dextenza resource
Formulary InformationFormulary Information resource
Coverage Authorization Request (Through OcuCare HCP Portal)Coverage Authorization Request (Through OcuCare HCP Portal) resource

Support for Getting Your Patient on Dextenza

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.