Lidocaine Topical – Lidocaine 5% Ointment Prior Authorization (with Quantity Limit) Criteria - Medicare Part D

Prior Authorization and Quantity Limit Criteria for Approval

Lidocaine 5% ointment will be approved when BOTH of the following are met:

1. The requested medication will be used for ONE of the following:
   1. Anesthesia of accessible mucous membranes of the oropharynx
      OR
   2. Anesthetic lubricant for intubation
      OR
   3. Temporary relief of pain associated with minor burns, including sunburn, abrasions of the skin, and insect bites
      OR
   4. Another indication that is supported in CMS approved compendia (e.g., cancer pain) for the requested medication AND ONE of the following:
      1. The patient has tried and had an inadequate response to a conventional therapy [e.g., gabapentin, pregabalin, oral prescription NSAID (non-steroidal anti-inflammatory drug)] for the requested indication
         OR
      2. The patient has an intolerance or hypersensitivity to a conventional therapy
         OR
      3. The patient has an FDA labeled contraindication to a conventional therapy
         AND
2. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. BOTH of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months