Pharmacy Prior Authorization Criteria

Brand Lidoderm Patch

Indications for Prior Authorization

Lidoderm (lidocaine patch 5%), Lidocan patch (lidocaine patch 5%), Brand Lidocan II patch (lidocaine patch 5%), Brand Lidocan III patch (lidocaine patch 5%), Brand Tridacaine (lidocaine patch 5%)

• For diagnosis of Post-herpetic neuralgia (PHN), Lidocan (lidocaine patch 5%)
  Indicated for relief of pain associated with post-herpetic neuralgia (PHN).

Criteria

Brand Lidoderm patch, Brand Lidocan patch, Brand Lidocan II patch, Brand Lidocan III patch (lidocaine patch 5%), Brand Tridacaine (lidocaine patch 5%)

Prior Authorization

Length of Approval: 12 Month(s)

• Diagnosis of post-herpetic neuralgia
AND
• Trial and intolerance to generic lidocaine patch 5%

P & T Revisions

2024-04-16, 2024-02-02, 2023-11-22, 2023-09-12, 2023-04-17, 2023-01-09, 2022-02-25, 2021-07-29, 2021-03-02, 2020-02-22

References

1. Lidoderm Prescribing Information. Endo Pharmaceuticals, Inc. Malvern, PA. November 2022.
2. Lidocan Prescribing Information. Rhodes Pharmaceuticals. Coventry, RI. December 2022.
3. Lidocan II Prescribing Information. Puretek Corporation. Panorama City, CA. October 2023.
4. Lidocan III Prescribing Information. Puretek Corporation. Panorama City, CA. January 2024.
5. Tridacaine Prescribing Information. Trifluent Pharma. San Antonio, TX. February 2024.

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Revision History

• 2024-04-16: update guideline
• 2024-02-02: Added Lidocan III 5% as target drug to the guideline. Updated references.
• 2023-11-22: Added Lidocan II 5% as target drug to the guideline.
• 2023-09-12: Added Lidocan 5% patch as target drug to guideline.
• 2023-04-17: Update to remove ZTLido
• 2023-01-09: Annual review
• 2022-02-25: Background updates.
• 2021-07-29: Product update
• 2021-03-02: Annual Review - Background updates.
• 2020-02-22: Updated references.

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