CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Lidoderm and ZTLido prior authorization and quantity limits

Defines prior authorization criteria, quantity limits, and approval durations for Lidoderm (lidocaine patch 5%) and ZTLido (lidocaine topical system 1.8%) for pain indications, affecting prescribers and pharmacists managing member coverage under Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLidoderm and ZTLido prior authorization and quantity limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with indication and, for continuation requests, documentation of a positive clinical response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90standard 30-day quantity limit

270standard 90-day quantity limit

3 monthsinitial approval

12–36 monthscontinuation approval

Coverage Criteria

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Coverage criteria

Covered when the following logical combinations are met

Permitted indications: Request is for pain associated with post‑herpetic neuralgia OR for pain associated with diabetic neuropathy OR for pain associated with cancer‑related neuropathy (including treatment‑related neuropathy)

Compendial uses include diabetic neuropathy and cancer‑related neuropathy.

Initial therapy: Request is NOT for continuation of therapy

Initial prior authorization duration: 3 months (per policies 125-C and 1182-C).

Continuation of therapy: Request is for continuation of therapy AND the patient has achieved or maintained a positive clinical response to the requested drug

Continuation prior authorization durations: policy 125-C = 36 months; policy 1182-C = 12 months.

Use of topical lidocaine products is limited to indicated populations. Lidoderm (lidocaine patch 5%) is indicated for relief of pain associated with post‑herpetic neuralgia (PHN) and must be applied only to intact skin. ZTLido (lidocaine topical system 1.8%) is indicated for relief of pain associated with PHN in adults.

Requests that do not meet the stated indication or continuation criteria are not covered. Specifically, prior authorization is required and coverage is limited to use for pain associated with post‑herpetic neuralgia (PHN) or approved compendial indications; requests that are not for an approved indication or that fail to meet the continuation requirement (see continuation criteria) may be denied.

For continuation requests, evidence that the patient has achieved or maintained a positive clinical response to the requested topical lidocaine product is required; absence of that documentation supports noncoverage.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage. The requested drug will be covered with prior authorization when it is prescribed for pain associated with post-herpetic neuralgia. Requests that do not meet the coverage criteria risk denial.

Prior Authorization required for all initial requests
Coverage indication: pain associated with post-herpetic neuralgia

Step Therapy

No step therapy requirements are specified for this drug in the source criteria.

Documentation Required

Clinical Response Documentation Required for Continuation

For continuation requests, documentation must show the patient has achieved or maintained a positive clinical response to the requested drug. Continuation approvals depend on evidence of ongoing benefit.

Continuation requests must document clinical benefit (e.g., symptom improvement, functional gain)
If continuation documentation is absent or inadequate, the request may be denied

Denial Risk

Coverage Criteria Noncompliance — Denial Risk

If the request does not meet the stated coverage criteria (e.g., not prescribed for post-herpetic neuralgia or lacks required continuation documentation), the request may be denied or returned for additional information.

Denial risk when criteria not met: non-approved indication, missing documentation for continuation
Requests not meeting prior authorization requirements may be denied

Background

Background: Topical lidocaine products in this policy include Lidoderm (lidocaine patch 5%) and ZTLido (lidocaine topical system 1.8%). Both products are intended for relief of pain associated with post‑herpetic neuralgia (PHN). Compendial uses listed in the source include pain associated with diabetic neuropathy and cancer‑related neuropathy.

Indications summary: Lidoderm is indicated for relief of pain associated with PHN and must be applied only to intact skin. ZTLido 1.8% is indicated for relief of PHN in adults.

Definitions

Post‑herpetic neuralgia (PHN) — FDA indication summary

DefinitionChronic neuropathic pain persisting after healing of herpes zoster; this is the FDA‑listed indication for Lidoderm and ZTLido.

Lidoderm FDA indicationIndicated for relief of pain associated with post‑herpetic neuralgia; apply only to intact skin.

ZTLido FDA indicationZTLido (lidocaine topical system) 1.8% is indicated for relief of pain associated with post‑herpetic neuralgia (PHN) in adults.

Compendial uses (related, not FDA)Compendial uses include pain associated with diabetic neuropathy and cancer‑related neuropathy.

Quantity and Frequency Limits

Topical lidocaine patches/systems — quantity limits

Standard 30‑day quantity limit90 patches per 25 days (25 days used to represent a 30‑day fill period).

Standard 90‑day quantity limit270 patches per 75 days (75 days used to represent a 90‑day fill period).

Purpose of adjusted day counts25‑day and 75‑day durations are used to allow time for refill processing when representing 30‑ and 90‑day fills.