Coverage Criteria — High-cost over-the-counter lidocaine patches
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Policy governs prior authorization and coverage criteria for high-cost over-the-counter (OTC) lidocaine patch preparations for Neighborhood Health Plan of Rhode Island members in the Medicaid portion of a FIDE SNP.
A maximum cost edit was implemented allowing OTC lidocaine patches under $200 per fill to adjudicate without authorization, while fills above $200 require prior authorization.
Coverage Criteria
Initial Therapy
Authorization may be granted when ALL of the following are met:
Continuation Therapy
Continuation may be approved when ALL of the following are met:
Authorization for high-cost over-the-counter lidocaine patch preparations will be granted only when all clinical criteria in Section I are satisfied. These requirements include: the product is used per its labeling or for an FDA-approved or compendia/peer-reviewed medically accepted indication; the prescribed dose and quantity are within product labeling or FDA/compendia-supported dosing; and documentation that the member has tried and failed all lower-cost formulary OTC lidocaine patch alternatives. Requests exceeding the cost threshold (see Coding section) also require documentation of prior failures of lower-cost formulary alternatives to be considered for approval.
Continuation of therapy may be approved when the patient meets all initial authorization criteria in Section I. Approvals for continuation should rely on the same documentation standards used at initiation, demonstrating ongoing use consistent with product labeling or compendia-supported indications and adherence to the previously approved dose and quantity.
Initial Therapy
Initial Therapy
Initial authorization criteria for high-cost OTC lidocaine patches
Continuation Therapy
Continuation
Continuation of therapy requires ongoing adherence to initial criteria.
Provider Actions & Prior Authorization
Prior authorization required for fills > $200
Prior authorization is required for any over-the-counter lidocaine patch fill that exceeds $200 per fill; approval requires meeting the clinical criteria in Section I and submission of required documentation of prior failures of lower-cost formulary OTC lidocaine patches.
Step requirement — trial of lower-cost formulary alternatives
Member must have tried and failed all lower-cost formulary alternative OTC lidocaine patch preparations; documentation of those tried and failed alternatives must be submitted with the request.
Required documentation for prior authorization
Documentation submitted for prior authorization must show use per product labeling or an FDA/compendia-supported medically accepted indication, that the prescribed dose and quantity fall within product labeling or compendia-supported dosing, and evidence that the member tried and failed all lower-cost formulary OTC lidocaine patch alternatives.
- Support for indication from product labeling, FDA approval, or recognized compendia/peer-reviewed literature
- Prescribed dose and quantity consistent with labeling or compendia dosing
- Evidence of tried and failed lower-cost formulary OTC lidocaine patch alternatives
Cost-edit rejection for fills > $200
Requests for OTC lidocaine patch fills with a cost greater than $200 per fill will reject at the pharmacy for the cost edit and will require prior authorization before adjudication.
Coding & Cost Thresholds
Step Therapy Requirements
| Step | Requirement | Documentation Required |
|---|---|---|
| 1 | ||
| Member must have tried and failed all lower-cost formulary alternative OTC lidocaine patch preparations before approval of the requested high-cost product. | ||
| Documentation of the tried and failed lower-cost formulary alternatives must be submitted with the request. |
Quantity Limits
Definitions
Background
Lidocaine topical patches are used for localized neuropathic pain and are available over-the-counter in multiple preparations and price points. To mitigate potential Fraud, Waste & Abuse, Neighborhood implemented a maximum cost edit effective for 2026 that permits OTC lidocaine patches costing under $200 per fill to adjudicate at the pharmacy without prior authorization. Fills above this threshold will reject for the cost edit and require prior authorization. The threshold was selected after a utilization review of August 2024–July 2025 claims, which showed an average cost per fill of $21.48 when very high-cost fills (> $500) were excluded, and was set to be at least 5× that analyzed average. Coverage duration for an approved authorization may be up to 12 months.
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