Lidoderm — Point32Health
any indication (life of plan coverage allowed)
Preferred products
- over-the-counter lidocaine 4% patches
Initial criteria
- Documentation of trial and failure, inadequate response, or clinical inappropriateness of the over-the-counter lidocaine 4% patches OR The patient is new to plan and is currently well controlled on lidocaine 5% patch, and the prescribing physician has documented that changing to the over-the-counter lidocaine patch alternative would result in adverse clinical outcomes
Approval duration
life of plan