CurrentCignaPolicy N/A

Topical Anesthetics Drug Quantity Management Policy - Per Days

Defines drug quantity management limits, exceptions, and medical-necessity criteria for topical anesthetics (lidocaine formulations and Pliaglis) for Cigna-administered plans.

Policy Summary

PayerCigna

PolicyTopical Anesthetics Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest quantity exceptions only when documented criteria are met; approvals are provided for 1 year unless noted and one-time approvals for 30 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50 gretail max per 30 days for lidocaine 5% ointment

30 gretail max per 30 days for Pliaglis

30 gretail max per 30 days for lidocaine 2.5%/prilocaine

1,800 mLexception per 30 days for lidocaine 2% jelly (self-catheterization)

150 gexception per 30 days for lidocaine 5% ointment (>2% BSA or >2×/day)

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Coverage and Exception Criteria

Quantity limit exception criteria

Exceptions to quantity limits are covered as medically necessary when the following criteria are met:

Lidocaine 2% jelly: If the patient is performing self-catheterization on a routine basis, approve 1,800 mL per 30 days at retail or 5,400 mL per 90 days at home delivery.1,800 mL / 30 days; 5,400 mL / 90 days

Lidocaine 5% ointment: If the patient needs anesthesia of accessible mucous membranes of the oropharynx > 2% of body surface area, approve 150 grams per 30 days or 450 grams per 90 days.150 g / 30 days; 450 g / 90 days

Lidocaine 5% ointment — alternative criterion: If the patient needs to administer lidocaine 5% ointment more frequently than twice per day, approve 150 grams per 30 days at retail or 450 grams per 90 days at home delivery.150 g / 30 days; 450 g / 90 days

Lidocaine 2.5%/Prilocaine 2.5% cream — 2.5 g use: If the patient needs topical anesthesia for > 12 separate dermal procedures utilizing 2.5 grams of cream each, approve 30 grams for each additional 12 minor dermal procedures per 30 days at retail or per 90 days at home delivery.30 g incremental per 12 procedures

Lidocaine 2.5%/Prilocaine 2.5% cream — 5 g use: If the patient needs topical anesthesia for > 6 separate dermal procedures utilizing 5 grams of cream each, approve 30 grams for each additional 6 minor dermal procedures per 30 days at retail or per 90 days at home delivery.30 g incremental per 6 procedures

The following uses are excluded from quantity limit overrides and are not recommended for additional coverage: use in any compounded formulations; cosmetic procedures or indications (examples include dermal filler injection, pulsed dye laser therapy, facial laser resurfacing, and laser-assisted tattoo removal); and treatment of peripheral neuropathic pain syndromes including peripheral or post-herpetic neuralgia, post‑traumatic peripheral neuropathy, or peripheral diabetic neuropathy.

Any exception request that does not meet the documented criteria is considered not medically necessary and approval of quantities beyond the established limits is not recommended. Quantity limit rules and the listed exception criteria govern coverage determinations for topical lidocaine formulations and Pliaglis; requests lacking required documentation or failing to meet the criteria will be denied as not medically necessary.

Provider Actions, Approvals, and Billing Notes

Prior Authorization

Coverage determinations require consideration

All coverage determinations require consideration of: (1) the terms of the applicable benefit plan document in effect on the date of service; (2) any applicable laws and regulations; (3) any relevant collateral source materials including coverage policies; and (4) the specific facts of the particular situation. Each request should be reviewed on its own merits and medical directors have discretion to exercise clinical judgment when making individual determinations.

Review the member's specific benefit plan document (e.g., Evidence of Coverage, SPD) — plan terms supersede this policy.
Consider federal/state mandates and applicable laws/regulations.
Consult related coverage policies and the clinical facts of the case.

Billing Rule

Product Definitions

Pliaglis — definition, indication, formulation

Generic/BrandPliaglis (lidocaine 7%/tetracaine 7%)

IndicationTopical local analgesia for superficial dermatological procedures on intact skin (e.g., dermal filler injection, pulsed dye laser therapy, facial laser resurfacing, laser-assisted tattoo removal)

Formulation & StrengthCream containing lidocaine 7% and tetracaine 7%

Package size30 gram tube

Administration timingApply to intact skin 20–60 minutes prior to procedure; amount depends on treated area (up to ~53 g may treat a 62 in² site)

Drug Quantity Limits and Dispensing Limits

lidocaine 2% jelly — maximums and availability

Productlidocaine 2% jelly (generic) — package sizes: 5 mL and 30 mL tubes

Retail maximum60 mL per 30 days

Home Delivery maximum180 mL per 90 days

Availability statusNo longer available (document notes: [no longer available])

Dose noteDo not exceed 30 mL (600 mg) in any 12-hour period; recommended dosing varies by indication

lidocaine 5% ointment — maximums

Product

Background and Clinical Context

Topical lidocaine formulations and combination topical anesthetics are indicated for local anesthesia of mucous membranes and intact skin for minor procedures, urethral procedures, intubation lubrication, and temporary relief of minor burns or abrasions. Formulation-specific dosing and practical maximums vary by product (for example, Pliaglis is sized to cover a 250 cm2 area per 30 g tube); quantity limits in this policy reflect typical per‑use amounts and intended frequency of use to prevent stockpiling, misuse, or overuse.

Policy Summary

PayerCigna

PolicyTopical Anesthetics Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest quantity exceptions only when documented criteria are met; approvals are provided for 1 year unless noted and one-time approvals for 30 days.

SourceLink

On This Page

Approval duration and Drug Quantity Management fallback

This Drug Quantity Management program is intended to limit stockpiling, misuse, and overuse of topical anesthetics. If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the policy criteria. All approvals are provided for 1 year in duration unless otherwise noted; one-time approvals are provided for 30 days.

If quantity limits are exceeded at point of sale, adjudication will follow the policy criteria.
Approvals default to 1 year; 'one-time' approvals = 30 days.

Note

Drug Quantity Management and quantity limits

Quantity limits for topical anesthetics are applied at point of sale. If the request does not meet the Drug Quantity Management rule at point of service, adjudication will follow the policy criteria.

Retail maximum quantities are enforced per 30 days; home delivery maximums per 90 days.
Examples include limits for lidocaine 2% jelly and lidocaine 5% ointment as listed in the Drug Quantity Limits section.

lidocaine 5% ointment (generic) — package sizes: 30 g, 35.44 g, 50 g tube/jar

Retail maximum50 grams per 30 days

Home Delivery maximum150 grams per 90 days

Application limitsSingle adult application should not exceed 5 grams; no more than ~17–20 g per day recommended in labeling

lidocaine 2.5%/prilocaine 2.5% cream — maximums

Productlidocaine 2.5%/prilocaine 2.5% cream (generic) — package sizes: 5 g and 30 g tubes

Retail maximum30 grams per 30 days

Home Delivery maximum90 grams per 90 days

Use cases/dosingTypical adult dosing: 2.5 g over 20–25 cm² for minor dermal procedures; larger procedures use specified dosing per cm²

Pliaglis — maximums (retail and home delivery)

ProductPliaglis (lidocaine 7%/tetracaine 7% cream) — package size: 30 g tube

Retail maximum30 grams (1 tube) per 30 days

Home Delivery maximum90 grams (3 tubes) per 90 days

Coverage noteRetail quantity equals coverage for ~250 cm² area; exceptions possible per criteria for larger areas or additional procedures