Synjardy 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: Apr 24, 2026

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated Apr 24, 2026
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated Apr 24, 2026
California - Uniform Prior Authorization FormCalifornia · Updated Apr 16, 2026
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc. · Updated Apr 24, 2026
Cigna - General Medication Prior Authorization FormCigna Corporation · Updated Apr 24, 2026
Colorado - Uniform Prior Authorization FormColorado · Updated Apr 16, 2026

ICD-10 codes for Synjardy Prior Authorizations

E11.9Type 2 diabetes mellitus without complications
E11.65Type 2 diabetes mellitus with hyperglycemia
I51.9Heart disease, unspecified
I50.9Heart failure, unspecified
I50.23Systolic (congestive) heart failure of left ventricle, chronic
I50.33Diastolic (congestive) heart failure of left ventricle, chronic
N18.9Chronic kidney disease, unspecified
N18.1Chronic kidney disease, stage 1
N18.2Chronic kidney disease, stage 2 (mild)
N18.3Chronic kidney disease, stage 3a
N18.4Chronic kidney disease, stage 4
N18.5Chronic kidney disease, stage 5

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