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Lidocaine Topical – Lidocaine/prilocaine 2.5%/2.5% cream Prior Authorization (with Quantity Limit) Criteria - Medicare Part D
Medicare Utilization Management Policy
Version Date: 01/01/2025

Prior Authorization and Quantity Limit Criteria for Approval

Lidocaine/prilocaine 2.5%/2.5% cream will be approved when BOTH of the following are met:

  1. The requested medication will be used for ONE of the following:
    1. Local analgesia on normal intact skin
      OR
    2. Topical anesthetic for dermal procedures
      OR
    3. Adjunctive anesthesia prior to local anesthetic infiltration in adult male genital skin
      OR
    4. Anesthesia for minor procedures on female external genitalia
      OR
    5. Another indication that is supported in CMS approved compendia for the requested medication
      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
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