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(lidocaine patch) Prior Authorization Request Form

(lidocaine patch) Prior Authorization Request Form 2025

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OptumRx has collaborated with CoverMyMeds to streamline the prior authorization process for Lidoderm® (lidocaine patch) requests, allowing for quicker determinations. The document includes a detailed request form requiring member and provider information, medication details, clinical information, and justifications for quantity limits or continuation of therapy. It emphasizes the importance of providing complete information to avoid denial of requests and outlines contact details for urgent inquiries.

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Versions	Form popularity	Fillable & printable
2018	4.4 Satisfied (29 Votes)
2017	4.3 Satisfied (61 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Are lidocaine patches covered under insurance?

A person may receive coverage for lidocaine patches through a Medicare Part D prescription drug plan or a Medicare Advantage (Part C) plan with prescription drug benefits.

What does a prior authorization consist of?

A prior authorization form will include information about you, your medical conditions, and your health care needs. Its important to fill out the form completely and accurately. Incomplete or incorrect information could delay your request or result in a denial.

What are FDA approved reasons for lidocaine patches?

INDICATION AND USAGE LIDODERM is indicated for relief of pain associated with post-herpetic neuralgia. It should be applied only to intact skin.

What diagnosis will cover lidocaine patches?

Requests for Lidoderm/Lidocaine 5% patches will be approved for patients suffering from one of the following conditions: Post-herpetic Neuralgia (PHN) Diabetic Neuropathic pain. Neuropathy due to cancer.

Can I submit a prior authorization myself?

The patient or their representative can contact their insurance company and provide the relevant information to start the Prior Authorization process. Its best to confirm with the healthcare provider if they have the information and are willing to submit the request.

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What is the new CMS rule on prior authorization?

Provider Notice, Including Denial Reason: Beginning in 2026, impacted payers must provide a specific reason for denied prior authorization decisions, regardless of the method used to send the prior authorization request. Such decisions may be communicated via portal, fax, email, mail, or phone.

What items are needed to submit a prior authorization request?

to the insurer: Patient name, date of birth, insurance policy number, and other relevant information. Physician and facility information (eg, name, provider ID number, and tax ID number) Relevant procedure and HCPCS codes for products/services to be provided/performed.

(lidocaine patch) Prior Authorization Request Form 2025

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Got questions?

Are lidocaine patches covered under insurance?

What does a prior authorization consist of?

What are FDA approved reasons for lidocaine patches?

What diagnosis will cover lidocaine patches?

Can I submit a prior authorization myself?

Complete this form in 5 minutes or less

People also ask

What is the new CMS rule on prior authorization?

What items are needed to submit a prior authorization request?

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