Follow the steps to effectively complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in an accessible editor.
2. Fill out the member information section, which includes required fields such as member name, insurance ID, date of birth, and address. Ensure all details are accurate.
3. Complete the provider information section. This will require the provider's name, NPI number, office phone, and address, again making sure that all information is correct.
4. In the medication information section, enter the medication name and strength. Indicate if you are requesting the brand version by checking the corresponding box.
5. Specify the directions for use and the dosage form in the designated fields.
6. Move to the clinical information section, where you will select the diagnosis. You may choose post-herpetic neuralgia or specify another diagnosis by providing the ICD-9/10 code.
7. If applicable, indicate any medications the patient has experienced failure, contraindication, or intolerance to, by checking the relevant boxes.
8. Complete the quantity limit requests section by stating the quantity requested per day and the reason for exceeding plan limitations, selecting the appropriate options provided.
9. Add any additional comments, diagnoses, symptoms, or information you believe is important for the review in the designated space.
10. Review all completed sections for accuracy. Once confirmed, proceed to save your changes, download the form, and/or print it for submission.

Begin filling out the Lidocaine Patch Prior Authorization Request Form online today to streamline the approval process.