Pharmacy Prior Authorization Criteria

Ztlido (lidocaine topical system)

Indications for Prior Authorization

ZTLIDO (lidocaine topical system)

• 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

1. Ztlido prescribing information. Scilex Pharmaceuticals Inc. Palo Alto, CA. April 2021.

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Revision History

• 2024-06-12: 2024 Annual Review
• 2023-06-19: 2023 Annual Review.
• 2022-10-31: Create New ST guideline

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