Susvimo 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 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
Colorado - Uniform Prior Authorization FormColorado · Updated Apr 16, 2026

ICD-10 codes for Susvimo Prior Authorizations

H35.32Exudative age-related macular degeneration
E10.311Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.311Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.32Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy
E11.32Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy
E10.339Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema
E11.339Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema

Appeal Templates

If the payer denies coverage, these templates help you build a stronger appeal.
Coverage Authorization Appeals Coverage Authorization Appeals resource
Letter of Medical NecessityLetter of Medical Necessity resource
A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.

Brand Resources

How To Order SusvimoHow To Order Susvimo resource
Susvimo Implantation Cartons Ordering GuideSusvimo Implantation Cartons Ordering Guide resource
Billing & Coding Guide: Implantation ProcedureBilling & Coding Guide: Implantation Procedure resource
Billing & Coding Guide: Wet AMDBilling & Coding Guide: Wet AMD resource
Billing & Coding Guide: Diabetic Macular Edema (DME)Billing & Coding Guide: Diabetic Macular Edema (DME) resource
Patient Consent Form (To be filled out with Prescriber Form)Patient Consent Form (To be filled out with Prescriber Form) resource

Support for Getting Your Patient on Susvimo

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.