Express Scripts Prior Authorization Form - Lidoderm 5% Transdermal Patch (Page 2 of 2) in pdf

Express Scripts Prior Authorization Form - Lidoderm 5% Transdermal Patch Page 2

 Yes

 No

 N/A

For Osteoarthritis (OA) diagnosis only, has the patient tried at least three other pharmacologic

therapies used to treat osteoarthritis (OA)?

If yes, please list other pharmacologic therapies tried: __________________________________

_______________________________________________________________________

Are there any other comments, diagnoses, symptoms, and/or any other information the

physician feels is important to this review?

____________________________________________________________________________________

Prescriber Signature: __________________________________________Date: ____________________

Office Contact Name: ___________________________ Phone Number: __________________________

Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you

have any questions about the process or required information, please contact our prior authorization team at the number listed on the

top of this form.

Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating

physician. Only a treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan

for the detailed information regarding benefits, conditions, limitations, and exclusions.

The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the

use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying,

distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you received this information in error,

please notify the sender immediately and arrange for the return or destruction of the documents.

Lidoderm 5% Transdermal Patch

8.9.2011

Express Scripts Prior Authorization Form - Lidoderm 5% Transdermal Patch Page 2