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lidocaine 5% patches — Medical Mutual

Osteoarthritis (OA)

Initial criteria

  • Tried at least three pharmacologic therapies, each one from a different class of medication used for osteoarthritis (e.g. acetaminophen, celecoxib, NSAIDs [etodolac, meloxicam, nabumetone], salicylates, intra-articular glucocorticoids, intra-articular hyaluronan, topical capsaicin, topical methylsalicylate)

Reauthorization criteria

  • Response to therapy required for continuation