Xiidra 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.

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

ICD-10 codes for Xiidra Prior Authorizations

H04.129Dry eye syndrome of unspecified lacrimal gland

Brand Resources

Access & ReimbursementPrior authorization and reimbursement resource for HCPs
Formulary InformationFormulary Information resource
PA ChecklistPA Checklist resource

Support for Getting Your Patient on Xiidra

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.