Prior Authorization Criteria Form printable pdf download

Prior Authorization Criteria Form

Prior Authorization Form

Lidoderm

This fax machine is located in a secure location as required by HIPAA regulations.

Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-888-836-0730.

Please contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process.

When conditions are met, we will authorize the coverage of Lidoderm.

Drug Name (select from list of drugs shown)

Lidocaine Patch 5%

Lidoderm (lidocaine patch 5%)

Quantity

Frequency

Strength

Route of Administration

Expected Length of Therapy

Patient Information

Patient Name:

Patient ID:

Patient Group No.:

Patient DOB:

Patient Phone:

Prescribing Physician

Physician Name:

Physician Phone:

Physician Fax:

Physician Address:

City, State, Zip:

Diagnosis:

ICD Code:

Comments:

Please circle the appropriate answer for each question.

1. Is lidocaine patch being prescribed for pain associated with

Y N

post-herpetic neuralgia?

[If yes, then no further questions.]

2. Is lidocaine patch being prescribed for pain associated with

Y N

diabetic neuropathy?

[If yes, then no further questions.]

3. Is lidocaine patch being prescribed for pain associated with

Y N

cancer-related neuropathy (including treatment-related

neuropathy [e.g. neuropathy associated with radiation

treatment or chemotherapy])?

Prior Authorization Criteria Form