CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Lidocaine topical patches/systems (Lidoderm, ZTLido) — prior authorization and quantity limits

Criteria for prior authorization and quantity limits for Lidoderm (lidocaine patch 5%) and ZTLido (lidocaine topical system 1.8%) for treatment of neuropathic pain indications; applies to medications administered/prescribed under the payer's pharmacy benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLidocaine topical patches/systems (Lidoderm, ZTLido) — prior authorization and quantity limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that the drug is prescribed for post‑herpetic neuralgia or a listed compendial neuropathic pain indication, and for continuation requests provide evidence of a maintained positive clinical response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9030‑day limit

27090‑day limit

3 monthsInitial DOA

12–36 moContinuation DOA

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria

Covered when the following logic is satisfied:

Indication: The requested drug is being prescribed for pain associated with post-herpetic neuralgia.

Initial vs Continuation

Continuation logic: Request is NOT for continuation of therapy
Continuation logic: Request is for continuation of therapy AND the patient has achieved or maintained a positive clinical response to the requested drug

Continuation requirement: For continuation requests, the patient has achieved or maintained a positive clinical response to the requested drug.

Requests for indications other than post‑herpetic neuralgia (PHN) or the listed compendial neuropathic pain conditions are not supported by this policy. Prior authorization will only be approved when the medication is prescribed for pain associated with PHN (see coverage criteria).

Use of Lidoderm or ZTLido for non‑PHN, non‑compendial neuropathic pain indications is not covered under this policy. Requests must specify an eligible neuropathic indication such as post‑herpetic neuralgia to meet the coverage requirement; otherwise the request will not be approved.

Covered Products & Quantity Limits

Covered products (brand name)mixedCovered

Lidoderm	lidocaine patch 5% (brand)
ZTLido	lidocaine topical system

Quantity limit per fill

Quantity limit (30-day fill)90 patches per 25 days (used for a 30-day fill period)

Quantity limit (90-day fill)270 patches per 75 days (used for a 90-day fill period)

Reason for unusual day period25-day and 75-day durations are used to allow time for refill processing

FREQUENCY LIMITS

Frequency limit (30-day)90 patches per 25 days

Frequency limit (90-day)270 patches per 75 days

Note on periods25 days corresponds to a 30-day fill period; 75 days corresponds to a 90-day fill period to allow refill processing

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. The request will be approved only when the medication is prescribed for pain associated with post‑herpetic neuralgia (PHN) or for specified compendial neuropathic pain indications (e.g., diabetic neuropathy, cancer‑related neuropathy) where applicable.

Requested drug must be prescribed for pain associated with post‑herpetic neuralgia (PHN).
Compendial neuropathic pain uses (e.g., diabetic neuropathy, cancer‑related neuropathy) may be considered where supported by references.

Step Therapy

There are no explicit step‑therapy (fail‑first) requirements specified for initial authorization; requests are evaluated against the indication and documentation criteria below.

Documentation Required

Indication Documentation

Prescribers must document the specific neuropathic pain indication on the prior authorization request (e.g., post‑herpetic neuralgia, diabetic neuropathy, cancer‑related neuropathy). Apply the product only to intact skin per prescribing information when relevant.

Document the exact diagnosis/indication for which the lidocaine topical product is prescribed.
If prescribing Lidoderm/ZTLido for PHN, note that these products are indicated for relief of pain associated with post‑herpetic neuralgia and should be applied to intact skin.

Documentation Required

Continuation Therapy Documentation

Continuation (renewal) requests must include documentation that the patient has achieved or maintained a positive clinical response to the requested drug. Requests for continuation will not be approved without evidence of clinical benefit.

Continuation requests must state prior duration of therapy and objective or patient‑reported evidence of improvement or maintained pain control.
The request must explicitly indicate it is for continuation of therapy and provide clinical notes supporting continued benefit.

Definitions

Lidoderm / ZTLido

Lidoderm (brand)Lidoderm — lidocaine patch indicated for relief of pain associated with post-herpetic neuralgia; for application to intact skin

ZTLido (brand)ZTLido — lidocaine topical system 1.8% indicated for relief of pain associated with post-herpetic neuralgia in adults

Product strengthsLidoderm: lidocaine 5% patch; ZTLido: lidocaine topical system 1.8%

Compendial uses

Supported compendial use — diabetic neuropathyPain associated with diabetic neuropathy is listed as a compendial use

Supported compendial use — cancer-related neuropathyPain associated with cancer-related neuropathy (including treatment-related neuropathy) is listed as a compendial use

ScopeCompendial uses are additional supported neuropathic pain indications beyond post-herpetic neuralgia

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLidocaine topical patches/systems (Lidoderm, ZTLido) — prior authorization and quantity limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Lidocaine topical patches/systems (Lidoderm, ZTLido) — prior authorization and quantity limits

Coverage Criteria

Covered Products & Quantity Limits

Provider Actions & Documentation Requirements

Conservative Treatment Requirements

Definitions

Background

Not Covered

Imaging Requirements