Express Scripts Prior Authorization Form - Lidoderm 5% Transdermal Patch
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1
2Prior Authorization Form
Lidoderm 5% Transdermal Patch
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 11-877-328-9799
applicable to all patients; certain plans and situations may require
If this an URGENT request, please call 1-800-753-2851
additional information beyond what is specifically requested.
Additional forms available:
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: _________________________________
Prescriber DEA/NPI (required): ______________________
Patient Last Name: _______________________________
Prescriber Phone #: _______________________________
Patient ID#: _____________________________________
Prescriber Fax #: _________________________________
Patient DOB: ____________________________________
Prescriber Address: _______________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Primary Diagnosis: _________________________________ ICD Code: ________________________________________
Directions for use (i.e. QD, BID, PRN & Qty): _________________________________________________________________________
Please complete the clinical assessment:
1. What is the indication or diagnosis?
□
□
Carpal Tunnel Syndrome
Postherpetic Neuralgia (PHN – pain that occurs after a shingles outbreak)
□
□
Low Back pain
Osteoarthritis (OA)
□
□
Myofascial pain
Other: __________________________________________________________
□
Neurophatic pain
__________________________________________________________
Yes
No
N/A
2. For Myofascial pain diagnosis only, will the Lidoderm Patch be used in combination with a standard
myofascial trigger point (MTP) treatment modality?
Yes
No
N/A
3. For low back pain diagnosis only, has the patient tried three other pharmacologic therapies commonly
used to treat low back pain?
If yes, please list other pharmacological therapies tried: ______________________________
_______________________________________________________________________
Yes
No
N/A
4. For Carpal Tunnel Syndrome diagnosis only, has the patient tried one other pharmacological therapy
used to treat carpal tunnel syndrome (e.g., steroids [oral or injectable], NSAIDs)?
If yes, please list other pharmacological therapies tried: __________________________________
_______________________________________________________________________
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