Reimbursement/Insurance Documents

Licart Reimbursement Guide

IBSA Pharma Inc. has developed this resource to support healthcare professionals (HCPs) navigate coverage, coding, and insurance coverage for Licart™ (diclofenac epolamine) topical system 1.3%. The information in this Reimbursement Guide is intended solely as a resource to assist the staff in physicians’ offices with certain insurance-related questions for Licart™.

Sample Letters of Medical Necessity and Appeal for Insurance Provider

Provided below are downloadable templates to reference and utilize at your convenience for insurance providers on behalf of Licart. These are not to be sent as is, fill in patient information as needed since these are not complete letters.

Download Sample Letter of Medical Necessity Download Sample Letter of Appeal

ICD-10 Codes

To see the full list of ICD-10 codes, click the button below

Download Licart ICD-10 Codes

Procedure Notes Forms

Highland Specialty Pharmacy Form Sterling Specialty Pharmacy Form Delta Drugs Specialty Pharmacy Form