Tyrvaya 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 Tyrvaya Prior Authorizations

H04.121Dry eye syndrome of right lacrimal gland
H04.122Dry eye syndrome of left lacrimal gland
H04.123Dry eye syndrome of bilateral lacrimal glands
H04.129Dry eye syndrome of unspecified lacrimal gland

Appeal Templates

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

Brand Resources

Pharmacy List Pharmacy List resource
PhilRx Prescription Fax Order Form PhilRx Prescription Fax Order Form resource
Formulary InformationFormulary Information resource
Prior Authorization Checklist Prior Authorization Checklist resource
Tier Exceptions For MedicareTier Exceptions For Medicare resource

Support for Getting Your Patient on Tyrvaya

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.