CurrentColorado Rocky Mountain Health PlansPolicy N/A

Lidocaine patch (Lidoderm, ZTLido) prior authorization

This document governs prior authorization and reauthorization criteria for lidocaine topical patches (Lidoderm and ZTLido) for treatment of neuropathic pain, affecting providers who request pharmacy coverage under the payer's clinical pharmacy program.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyLidocaine patch (Lidoderm, ZTLido) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date3/1/2026

Next Review DateN/A

Key ActionFor initial approval, document diagnosis of PHN or neuropathic pain and confirm patch will be applied only to intact skin.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moinitial authorization duration

12 moreauthorization duration

2named products covered

2indications listed

Coverage Criteria

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Brand Lidoderm is typically excluded from coverage per the policy footnote. The policy applies to both brand and generic lidocaine patches but specifically notes that Brand Lidoderm is typically excluded, so providers should expect coverage determinations to favor generic or alternative labeled products unless an exception is documented.

Provider Actions & Requirements

Prior Authorization

Initial Authorization Requirements

Initial authorization will be issued for 12 months. Lidocaine patch or ZTLido will be approved only when both of the following are met: (1) diagnosis of post-herpetic neuralgia or neuropathic pain; AND (2) patch will be applied only to intact skin.

Required diagnosis: post-herpetic neuralgia or neuropathic pain
Patch application: intact skin only
Authorization duration: 12 months

Step Therapy

Step / Automated Approval Note

Automated processes or review of prior claims/medication history and diagnosis codes (ICD-10) may be used to approve initial requests without a full clinical submission. Providers and pharmacies should be aware that program-specific automation may vary and could approve based on claim logic alone.

Approval may be based on prior claim/medication history and ICD-10 diagnosis codes
Use of automation varies by program/therapeutic class

Documentation Required

Reauthorization Documentation

Reauthorization requires documentation of a positive clinical response to therapy. Be prepared to submit clinical notes or other evidence showing therapeutic benefit for continued coverage.

Documentation of positive clinical response required for reauthorization

Note

Program Automation and Supply Limits

Automated approval and re-approval processes vary by program and therapeutic class; prior-approval waivers based on claims history are possible. Supply limits may apply — confirm allowable quantity and dispensing limits when submitting or expecting automated approvals.

Automated approval/re-approval processes are variable
Supply limits may be in place

Initial Therapy

inv-10: Initial Therapy

Initial authorization criteria for therapy:

Initial: Diagnosis of post-herpetic neuralgia OR diagnosis of neuropathic pain

Initial approval for 12 months

Application site: Patch will be applied only to intact (unbroken) skin

Step Therapy & Automated Approvals

Step	Program rule	Approval basis / criteria	Initial supply / duration	Reauthorization / renewal
1	Program may use automated step edits or claim-based logic	May approve initial and re-authorization based on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic without full clinical documentation	Initial authorization issued for 12 months	Reauthorization issued for 12 months; requires documentation of positive clinical response to therapy when clinical review is performed

Definitions

Intact skin (definition)

DefinitionPatch must be applied only to skin that is unbroken (intact skin)

Condition of ApprovalApplication to intact (unbroken) skin is required for initial authorization of lidocaine patches (Lidoderm, ZTLido)

Related RequirementInitial authorization requires both a qualifying diagnosis and that the patch be applied only to intact skin

Background

Lidocaine topical patches (including Lidoderm and ZTLido) are indicated for relief of pain associated with postherpetic neuralgia (PHN) and other neuropathic pain conditions. The policy requires that initial authorization meets both clinical and application conditions: a diagnosis of PHN or neuropathic pain and that the patch will be applied only to intact skin. Initial approvals are issued for 12 months.

For continued coverage, reauthorization requires documentation of a positive clinical response to therapy; reauthorizations are also issued for 12 months. Program processes may use prior claim history, diagnosis codes, or automated claim logic to approve initial or reauthorization requests, and state mandates or member benefit terms may also affect coverage.