Centene Lidocaine Transdermal Coverage Update

Coverage Criteria

Initial Approval — Post-herpetic Neuralgia

Covered when ALL of the following are met

Initial PHN criteria: 1. Diagnosis of post-herpetic neuralgia secondary to herpes zoster; 2. Age ≥ 18 years; 3. For requests exceeding a 30 day supply (>90 patches/topical systems for Lidoderm and ZTlido; >60 topical systems for Bondlido), member must meet both of the following (a and b): (a) Failure of a ≥30 day trial of gabapentin at doses ≥1,800 mg/day unless contraindicated or clinically significant adverse effects are experienced; (b) If member is ≤64 years of age: failure of a ≥30 day trial of one tricyclic antidepressant (eg, amitriptyline, nortriptyline, desipramine) unless contraindicated or clinically significant adverse effects are experienced; 4. Member must use generic lidocaine transdermal patch, unless contraindicated or clinically significant adverse effects are experienced; 5. Request does not exceed daily limits: (a) Lidoderm and ZTlido: 3 patches/topical systems per day; (b) Bondlido: 2 topical systems per day.supply and daily limits apply

Illinois HIM requests: step therapy requirements do not apply as of 1/1/2026 per IL HB 5395.

Initial Approval — Diabetic Neuropathy (off-label)

Covered when ALL of the following are met

Initial diabetic neuropathy criteria: 1. Diagnosis of diabetic neuropathy; 2. Age ≥ 18 years; 3. Request is for Lidoderm; 4. Member must use generic lidocaine transdermal patch, unless contraindicated or clinically significant adverse effects are experienced; 5. For requests exceeding a 30 day supply (>90 patches), member must meet all of the following: (a) Failure of a ≥30 day trial of gabapentin at doses ≥1,800 mg/day unless contraindicated or clinically significant adverse effects are experienced; (b) If member is ≤64 years of age: failure of a ≥30 day trial of one tricyclic antidepressant (eg, amitriptyline, nortriptyline, desipramine, imipramine) at up to maximally indicated doses unless contraindicated or clinically significant adverse effects are experienced; (c) Failure of a ≥30 day trial of an SNRI (duloxetine, extended-release venlafaxine, desvenlafaxine) at up to maximally indicated doses unless contraindicated or clinically significant adverse effects are experienced; 6. Request does not exceed 3 patches per day.supply and daily limits apply

Approval duration: 6 months.

Initial Therapy — Initial therapy criteria differ by indication; failures of specified systemic agents required for extended supplies.

Initial therapy criteria differ by indication; failures of specified systemic agents required for extended supplies.

Initial therapy overview: See indication-specific criteria for post-herpetic neuralgia and diabetic neuropathy. Each lists diagnosis, age ≥18, requirement to use generic lidocaine transdermal patch unless contraindicated, daily product limits, and additional prior systemic therapy trials required when the request exceeds a 30-day supply (see individual indication nodes).

Initial Therapy — Initial therapy criteria were periodically revised; policy emphasizes guideline-based systemic options and limits quantity/duration redirection

Initial therapy criteria were periodically revised; policy emphasizes guideline-based systemic options and limits quantity/duration redirection

Initial therapy notes: Policy revisions (3Q 2022, 3Q 2024, 3Q 2025) clarified redirection to systemic therapy when requests exceed a 30-day supply, updated preferred examples of systemic agents (TCAs, SNRIs), revised to prefer generic transdermal lidocaine in criteria, and added Bondlido as a new product. Step therapy for PHN includes an Illinois HIM bypass per IL HB 5395 (3Q 2025).

See policy history for details.

Continuation Therapy (All Indications in Section I)

Covered when ALL of the following are met

Continuation: 1. Member meets one of the following: (a) currently receiving medication via Centene benefit or previously met initial approval criteria; OR (b) member is currently receiving medication and is enrolled in a state and product with continuity of care regulations; 2. Member is responding positively to therapy; 3. Member must use generic lidocaine transdermal patch, unless contraindicated or clinically significant adverse effects are experienced; 4. If request is for a dose increase, new dose does not exceed daily limits: (a) Lidoderm and ZTlido: 3 patches/topical systems per day; (b) Bondlido: 2 topical systems per day.

Approval duration: 12 months.

Continuation Therapy — Continuation therapy requires evidence of prior approval or current therapy and positive response.

Continuation therapy requires evidence of prior approval or current therapy and positive response.

Continuation requirements: 1. Member is currently receiving medication via Centene benefit or previously met initial approval criteria OR continuity of care applies; 2. Member is responding positively to therapy; 3. Member must use generic lidocaine transdermal patch unless contraindicated; 4. Dose increases must not exceed product-specific daily limits (Lidoderm/ZTlido: 3 patches/day; Bondlido: 2 topical systems/day).

3Q 2024 update added requirement to trial generic lidocaine patches before approving brand products for continued therapy.

Continuation Therapy — Continued therapy requirements updated in 3Q 2024 review.

Continued therapy requirements updated in 3Q 2024 review.

Continued therapy requirements: Continuation requires prior trial of generic lidocaine patches before approving brand products for continued therapy.

From 3Q 2024 annual review.

Non‑FDA approved indications that are not specifically addressed in this policy are not authorized unless the provider submits sufficient documentation demonstrating efficacy and safety in accordance with the applicable off‑label use policies (for example, CP.CPA.09 for Commercial and HIM, PA.154 for Health Insurance Marketplace, and CP.PMN.53 for Medicaid) or other applicable evidence of coverage documents.

Uses of lidocaine transdermal products for non‑FDA approved indications that lack adequate supporting documentation consistent with the referenced off‑label use policies are not authorized and may be denied.

When state Medicaid coverage provisions conflict with the coverage statements in this clinical policy, the state Medicaid provisions take precedence. Providers should consult the applicable state Medicaid manual for any state‑specific coverage rules that supersede this policy.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — Prior authorization requires documentation that member meets the specified initial or continuation criteria (diagnosis, age, trials of systemic agents, etc.). Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that member has met all approval criteria. Requests lacking required documentation or evidence that the member meets all approval criteria may be denied.

Prior authorization is required for lidocaine transdermal products per policy criteria.
Submit office notes, relevant labs, medication trial documentation, and any other clinical information demonstrating criteria are met.

Documentation Required

Documentation Standards

Documentation standards and annual review updates standardized member-use and documentation language. Providers should ensure submitted documentation follows the most recent policy updates (including generic-first language and any product-specific requirements) and reference the clinical rationale for approval.

Coding and Product Availability

Product availability (no explicit codes provided)NDC

NDCs not listed

No NDC codes provided in this chunk; product availability described instead

Maximum patches/topical systems per day — summary

Lidoderm / ZTlido maximum3 patches/topical systems per day

Bondlido maximum2 topical systems per day

Manufacturer/application guidanceManufacturer notes that up to 3 patches may be applied to cover the most painful area for up to 12 hours within a 24-hour period

Definitions

Lidocaine transdermal products

Included productsLidoderm (lidocaine patch 5%), ZTlido (lidocaine topical system 1.8%), Bondlido (lidocaine topical system 10%)

Therapeutic classTopical/transdermal local anesthetic (lidocaine)

Primary useUsed for symptomatic relief of pain associated with post-herpetic neuralgia (Lidoderm is FDA-approved; Bondlido and ZTlido indicated for PHN in adults)

Postherpetic neuralgia (PHN)

DefinitionPostherpetic neuralgia (PHN): persistent neuropathic pain following herpes zoster infection

FDA indication noteLidoderm is indicated for relief of pain associated with post-herpetic neuralgia; Bondlido and ZTlido are indicated for PHN in adults

Initial Therapy Criteria

inv-20: Initial Therapy — Initial therapy criteria differ by indication; failures of specified systemic agents required for extended supplies.

Initial therapy criteria differ by indication; failures of specified systemic agents required for extended supplies.

Initial therapy overview duplicate: See indication-specific criteria for PHN and diabetic neuropathy; extended supplies (>30 days) require documented trials of gabapentin ≥1,800 mg/day for ≥30 days and, depending on age and indication, trials of a TCA and/or an SNRI at maximally indicated doses unless contraindicated.

inv-21: Initial Therapy — Initial therapy criteria were periodically revised; policy emphasizes guideline-based systemic options and limits quantity/duration redirection

Initial therapy criteria were periodically revised; policy emphasizes guideline-based systemic options and limits quantity/duration redirection

Initial therapy notes duplicate: Policy updates across 3Q 2022–3Q 2025 clarified redirection to systemic therapy when requests exceed 30 days, added desvenlafaxine as an SNRI example for diabetic neuropathy (3Q 2024), preferred generic transdermal lidocaine in policy language, and added Bondlido as a new product (RT4).

Continuation Criteria

inv-22: Continuation Therapy — Continuation therapy requires evidence of prior approval or current therapy and positive response.

Continuation therapy requires evidence of prior approval or current therapy and positive response.

Continuation duplicate: Member currently receiving medication via Centene benefit or previously met initial approval criteria OR continuity of care applies; member responding positively to therapy; must use generic lidocaine unless contraindicated; dose increase must not exceed product-specific daily limits (Lidoderm/ZTlido: 3 patches/day; Bondlido: 2 topical systems/day).

Approval duration: 12 months.

inv-23: Continuation Therapy — Continued therapy requirements updated in 3Q 2024 review.

Continued therapy requirements updated in 3Q 2024 review.

Continued therapy requirements duplicate: Continuation requires prior trial of generic lidocaine patches before approving brand products for continued therapy.

From 3Q 2024 annual review.

Step Therapy Requirements

Coverage requirement	Details
Trial of gabapentin for >30-day supplies
For requests exceeding a 30-day supply (>90 patches/topical systems for Lidoderm and ZTlido; >60 topical systems for Bondlido), member must have failed a ≥30-day trial of gabapentin at doses ≥1,800 mg/day unless contraindicated or adverse effects occurred.
Age‑dependent secondary step (TCAs)
If member is ≤64 years of age, must have failed a ≥30-day trial of one tricyclic antidepressant (e.g., amitriptyline, nortriptyline, desipramine, imipramine) unless contraindicated or adverse effects occurred.
SNRI requirement for diabetic neuropathy
For diabetic neuropathy requests exceeding a 30-day supply, member must have failed a ≥30-day trial of an SNRI (duloxetine, extended‑release venlafaxine, desvenlafaxine) at up to maximally indicated doses unless contraindicated or adverse effects occurred.
Generic-first requirement
Member must use generic lidocaine transdermal patch unless contraindicated or clinically significant adverse effects are experienced.
Daily limits
Requests must not exceed daily limits: Lidoderm and ZTlido — 3 patches/topical systems per day; Bondlido — 2 topical systems per day.
Approval duration
Initial approval duration: 6 months.

Coverage requirement	Details / State exception
Step therapy applies for postherpetic neuralgia
For postherpetic neuralgia requests that exceed a 30-day supply, step therapy requirements (including a ≥30-day gabapentin trial at ≥1,800 mg/day and age‑dependent TCA trial) apply as specified in the policy.
Illinois HIM bypass (IL HB 5395)
For Illinois HIM requests, the step therapy requirements do not apply as of 1/1/2026 per IL HB 5395 (step therapy bypass for IL HIM).
Policy history note
3Q 2025 annual review added the step therapy bypass for IL HIM per IL HB 5395; Bondlido was later added to the policy (RT4).

Quantity Limits

Lidoderm / ZTlido — daily limit

Maximum per day (actionable)3 patches/topical systems per day for Lidoderm and ZTlido

Application duration guidanceApply up to 3 patches at once to intact skin to cover the most painful area for up to 12 hours within a 24-hour period

Approval contextDaily limit cited in initial and continuation criteria and applied to dose increases

Bondlido — daily limit

Maximum per day (actionable)2 topical systems per day for Bondlido

Application duration guidanceApply up to 2 topical systems to intact skin to cover the most painful area for up to 12 hours within a 24-hour period

Background

Lidocaine transdermal products are topical amide local anesthetics used for symptomatic relief of neuropathic pain. Lidoderm (lidocaine patch 5%) is FDA‑approved for relief of pain associated with post‑herpetic neuralgia (PHN) and should be applied only to intact skin. The policy also includes other topical systems such as ZTlido and Bondlido, which are topical lidocaine systems with product‑specific strengths and instructions; the policy treats these agents within the same topical local anesthetic class for coverage considerations.

OpenPayer

Lidocaine Transdermal (Bondlido, Lidoderm, ZTlido)

Coverage Criteria

Provider Actions and Requirements

Coding and Product Availability

Definitions

Initial Therapy Criteria

Continuation Criteria

Step Therapy Requirements

Quantity Limits

Background