Ztlido (lidocaine topical system)
Indications for Prior Authorization
ZTLIDO (lidocaine topical system)
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For diagnosis of Pain with Post-Herpetic Neuralgia
Indicated for relief of pain associated with post-herpetic neuralgia (PHN) in adults.
Criteria
Ztlido
Step Therapy
Length of Approval: 12 Month(s)
- Requested drug is being used for a Food and Drug Administration (FDA)-approved indication AND
- Trial and failure (of a minimum 30-day supply), or intolerance to generic lidocaine 5% patch
P & T Revisions
2024-06-12, 2023-06-19, 2022-10-31
References
- Ztlido prescribing information. Scilex Pharmaceuticals Inc. Palo Alto, CA. April 2021.
Revision History
- 2024-06-12: 2024 Annual Review
- 2023-06-19: 2023 Annual Review.
- 2022-10-31: Create New ST guideline
HEALTHY LIVING