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Lidocaine patch () Prior Authorization Request Form

Lidocaine patch () Prior Authorization Request Form 2025

Lidocaine patch () Prior Authorization Request Form Preview on Page 1

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OptumRx has partnered with CoverMyMeds to streamline the prior authorization process for Lidocaine patch (Lidoderm®) requests, allowing for real-time determinations. The document includes a detailed request form that requires specific member and provider information, medication details, clinical information, and prescriber attestation. It emphasizes the importance of submitting complete information within established timelines to avoid denial of requests.

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Click ‘Get Form’ to open the Lidocaine patch Prior Authorization Request Form in the editor.
Begin by filling out the 'Member Information' section. Enter the member's name, insurance ID, date of birth, and contact details.
Next, complete the 'Provider Information' section with your name, NPI number, office phone, and address.
In the 'Medication Information' section, specify the medication name, strength, dosage form, and whether you are requesting a brand version.
Indicate if this is a continuation of therapy and answer related questions regarding previous medication usage.
Fill out the 'Clinical Information' section by selecting the requested drug and diagnosis. Provide any necessary clinical history.
Finally, ensure that all required fields are completed before signing and dating the form in the prescriber attestation area.

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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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Got questions?

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

Can my doctor prescribe lidocaine patches?

Prescription lidocaine transdermal comes as a 5% patch (Dermalid, Lidoderm) and as a 1.8% topical system (Ztlido) to apply to the skin. Prescription lidocaine transdermal is applied only once a day as needed for pain.

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.

Does insurance pay for lidocaine patches?

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 is a prior authorization request form?

Prior authorization (prior auth, or PA) is a management process used by insurance companies to determine if a prescribed product or service will be covered. This means if the product or service will be paid for in full or in part.

What is lidocaine 5% patch FDA approved indication?

LIDODERM is indicated for relief of pain associated with post-herpetic neuralgia. It should be applied only to intact skin. LIDODERM is contraindicated in patients with a known history of sensitivity to local anesthetics of the amide type, or to any other component of the product.