OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request Form 2017 free printable template

Select the requested drug below Select the diagnosis below Neuropathic pain Post-herpetic neuralgia Other Brand Will the patch be applied only to intact skin Yes No Medication history For brand requests answer the following Does the member have a history of failure contraindication or intolerance to lidocaine transdermal patch generic Yes No Reauthorization If this is a reauthorization request answer the following Is the member currently on the requested medication Yes No Is there...

How to fill out OptumRx Lidoderm Lidocaine Patch Prior Authorization

How to fill out OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request

1. Obtain the OptumRx Lidoderm Prior Authorization Request form from your healthcare provider or the OptumRx website.
2. Complete the patient’s information section, including full name, date of birth, and insurance details.
3. Provide the prescribing physician's information, including name, contact number, and NPI number.
4. Indicate the specific condition for which Lidoderm is being prescribed.
5. Include the dosage and frequency of the Lidoderm (Lidocaine Patch) as prescribed by the physician.
6. Attach relevant medical records that support the necessity of the Lidoderm treatment.
7. Sign and date the request form as the healthcare provider or authorized representative.
8. Submit the completed request form to OptumRx via the designated method (fax, mail, or online submission) and keep a copy for your records.

Who needs OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request?

1. Patients with chronic pain conditions such as postherpetic neuralgia or diabetic neuropathy requiring topical analgesia.
2. Individuals who have not found adequate relief from alternative pain management therapies.
3. Patients who have been specifically prescribed Lidoderm by their healthcare provider for legitimate medical reasons.

People Also Ask about

Can you buy lidocaine pain patches over-the-counter?

Lidocaine patches are easily found over the counter (OTC) at your local pharmacy as well as stores online like Curist, and do not need a prescription.

What are the FDA approved indications for lidocaine patch?

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.

How do you get prescription lidocaine patches?

The lidocaine 5% patch and lidocaine 1.8% patch are prescription (RX) only, which means it requires a doctor to write a prescription.

What is lidocaine patch approved for?

It is mainly used for relief of neuropathic (nerve) pain, especially in areas where it is particularly sensitive to touch. Lidocaine 5% patches are licensed for the treatment of Post Herpetic Neuralgia but have also been found to be useful for other types of neuropathic pain.

Do you need a prescription for lidocaine patch 5%?

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.

Do you need a script for lidocaine patch?

It can cause skin irritation, but it's typically mild and temporary. The lidocaine patch is available by prescription and as an over-the-counter (OTC) medication.

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What is OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request?

OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request is a formal request submitted to obtain approval from OptumRx before prescribing the Lidoderm patch, which is used for pain management.

Who is required to file OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request?

The prescribing healthcare provider or their office staff is typically required to file the OptumRx Lidoderm Prior Authorization Request on behalf of the patient.

How to fill out OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request?

To fill out the request, healthcare providers must complete a form with patient information, medical history, treatment plans, and justification for the use of Lidoderm.

What is the purpose of OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request?

The purpose of the Prior Authorization Request is to ensure that the Lidoderm patch is medically necessary for the patient and to manage costs by preventing unnecessary prescriptions.

What information must be reported on OptumRx Lidoderm (Lidocaine Patch) Prior Authorization Request?

The information that must be reported includes patient demographics, diagnosis, prior treatments, expected outcomes, and any supporting clinical documentation.