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

For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

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

1970-01-01, 2025-12-18, 2025-09-03, 2024-06-12, 2023-06-19, 2022-10-31

References

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

---

Revision History

• 1970-01-01: No criteria changes
• 2025-12-18: no criteria changes, added IL statute operational note
• 2025-09-03: 2025 Annual Review. No criteria changes
• 2024-06-12: 2024 Annual Review
• 2023-06-19: 2023 Annual Review.
• 2022-10-31: Create New ST guideline

---