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Drug - Lidoderm (lidocaine patch 5%) [Endo Pharmaceuticals]

September 2015

Therapeutic area - Topical Anesthetic

Approval criteria

New Patients

Approval criteria depend on the intended use for Lidoderm. Therefore, there are separate prior authorization criteria; one for post-herpetic neuralgia (PHN) and another for non-PHN.

Post-Herpetic Neuralgia (PHN) Approval Criteria

  • Patient has a diagnosis of post-herpetic neuralgia AND
  • Patient has tried and failed at least three of the following drugs: topical capsaicin, gabapentin, nortriptyline, amitriptyline, desipramine, maprotiline, pregabalin

Other diagnosis (diagnosis does not equal PHN)

  • Patient has tried and failed one legend NSAID AND
  • Patient has tried and failed one the following tri-cyclic antidepressants (nortriptyline, amitriptyline, desipramine, maprotiline) AND
  • Patient has tried and failed gabapentin  

Lidoderm and its generics are subject to quantity level limits of 90 patches in addition to the prior authorization criteria.


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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