Lidocaine Patches and Prior Authorizations

July 30, 2016 • Prescription Drugs • Views: 5488

If the conversation has happened once, it has sadly happened a million times:

Patient:  “Hi, my name is Mr. Smith, I’m here to pick up my prescription.”

Pharmacist or Tech:  “Okay.  Great.  Let’s see.  Oh….The doctor prescribed you something known as a Lidocaine patch.  Unfortunately it is not covered by your insurance.  If you want to pay for it, the price would be $250 (depending on amount ordered).  Or we could ask your doctor to try and get it approved.”

Lidocaine patches OFTEN require a prior authorization.  But why!?  Allow me to explain and also to offer some suggestions.  Please understand that this post is NOT an attempt to give you medical advice.  It is intended for informational purposes only.   

BACKGROUND:

Lidocaine patches first became available back in 1999 under the name “Lidoderm” patches.  They were developed by a company known as Hind Health Care, who entered into a marketing and sales agreement with Endo Pharmaceuticals to distribute the product.  Here’s the important part.  Lidoderm was approved for the treatment of something called post-herpatic neuralgia (pain from shingles).  Also note that it should only be applied to intact skin (that’s the pharmacist in me wanting to be sure it is used right!).

A few years ago the patent ran out and generic versions of Lidoderm are now on the market.  While the generic versions cost about half what the original Lidoderm product used to run, they are still pretty expensive.  Without insurance, expect to pay somewhere in the neighborhood of $150 to $200 for a box of 30 patches.

PRIOR AUTHORIZATION:

The reason why lidocaine patches so often require prior authorization is that they are expensive (when compared to other forms of treatment like NSAIDs, muscle relaxants or even opiates) AND because they were actually only approved to treat pain related to shingles.  As such, health plans have decided (cruelly in my opinion) to often block access to the patches for patients when they are prescribed for other indications such as back pain or other forms of pain.  You see, doctors may prescribe lidocaine patches for “off-label” usage, and this is done all the time.  But in the case of lidocaine patches, many insurance companies have drawn a hard line and simply refuse to allow them for any other purpose.

For example:

The published prior authorization (PA) criteria for approving lidocaine patches for PBM Caremark are as follows:

  1. Does the patient have a diagnosis of pain associated with post-herpetic neuralgia?
  2. Is the skin where the patch is to be applied intact?
  3. Does the patient have sensitivity to local anesthetics of the amide type?
  4. Is the patch being applied for more than 12 hours in a 24 hour period?

The above criteria all come from the approved indications and package insert information for lidocaine patches.  But if the doctor indicates, for example, that the patch is NOT being used for post-herpetic neuralgia, you can be pretty sure the request will be denied.

Another example is the PA criteria from Massachusetts Medicaid for lidocaine patches:

Documentation of all the following is required:

diagnosis of pain associated with post-herpetic neuralgia; and request is for ≤ 90 patches per month; and

one of the following:

  • medical necessity for transdermal formulation; or

both of the following:

  • inadequate response (defined as at least four weeks of therapy), adverse reaction or contraindication to a tricyclic antidepressant (TCA); and
  • one of the following anticonvulsants:
  1. inadequate response (defined as at least two weeks of therapy with a minimum dose of 1,200 mg/day), adverse reaction or contraindication to gabapentin; or
  2. inadequate response (defined as at least two weeks of therapy with a minimum dose of 150 mg/day), adverse reaction or contraindication to pregabalin.

HOW TO DEAL WITH LIDOCAINE PATCH PRIOR AUTHORIZATIONS:

So how do you deal with this situation as a patient or as a pharmacist or pharmacy technician?  The following is just my advice.  I am not suggesting this is how you personally have to handle it.  But this is the way we typically approach the situation in pharmacies that I manage.

FIRST, always try to bill your primary insurance to see if it is covered.  Some plans will cover these patches without any approvals required at all.

SECOND, if they are NOT covered, ask the pharmacy if they would be willing to notify your doctor’s office of the need for a prior authorization.  Most pharmacies will at least FAX a notification for you to your doctor.  This process can take several days or longer to happen.  

THIRD, consider USING A DISCOUNT CARD.  Ask the pharmacy for the CASH price of the lidocaine patch prescription.  A discount card is not insurance.  They are generally a FREE PBM-sponsored program that will discount the prescription, sometimes substantially.  Need a FREE discount card for your lidocaine patch prescription?  CLICK HERE!

FOURTH, consider paying for a smaller supply of the patches while you wait to see if your insurance will approve them.  Using the discount card mentioned above, ask the pharmacy to use the card to process a prescription for 7 lidocaine patches (1 week).  See what the price is and decide if you can afford to pay that amount.  This will give you the chance to try the patches and IF your insurance approves, you may be able to get reimbursed.

FIFTH, consider trying a relatively new OTC cream called Aspercreme with Lidocaine.  This product contains 4% lidocaine (the prescription patch contains 5%).  It can be applied topically and is available in many pharmacies or BUY IT ONLINE HERE.

CONCLUSION:

If you are a patient frustrated with the need for prior authorization of your prescription for lidocaine patches, I fully understand.  With all the side-effects of NSAID’s and the dangers of muscle relaxants and opiates, it is a shame that a non-drowsy and non-addicting, topical approach to pain requires so many hurdles to obtain.  I hope the above solutions give you some help.  If you have more questions about getting lidocaine patches for your pain, feel free to contact me.

©Jason Poquette and The Honest Apothecary.  Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts, quotes and links may be used, provided that full and clear credit is given to Jason Poquette and The Honest Apothecary with appropriate and specific links to the original content.


 

Author: Jason Poquette

5 Responses to Lidocaine Patches and Prior Authorizations

  1. Eric Saul,RPh says:

    Just for the sake of discussion, this is mandated that the plan check this usage by CMS not some desire by the plan to be a dark overlord and see members writhing in pain. One plan I know of had a retrospective audit done and had to pay CMS back lots of money for inappropriately covering this product. Hopefully someone in the industry will get their act together and do the studies to broaden the indication. Until then this situation will continue to rear its ugly head.

  2. jasonpoquette says:

    Hi Eric, Thanks for the information. I’m genuinely curious why all “off label” uses are not, by that logic, also de facto excluded. It does seem that lidocaine is being unfairly targeted?

  3. Chantel York says:

    My grandmother just told me that while at the Walgreens pharmacy, she asked about these patches for me since the ones she bought over the counter seems to be helping me with my chronic pain, and if Medicaid covered the patches… The pharmacist there told her that Medicaid did… She called my doctor and of in a request for them for me… But everything I’m reading says they don’t and I would really hate to have my boyfriend drive all the way down to the pharmacy if he’s going to be told that it’s hundreds of dollars. =.

  4. kristine08 says:

    I am using them for post XLIF fusion scar-area, “bee-sting-like” pain and sometimes it feels like a spider is biting me. This is 5 months post op.
    I called my neurosurgeon and he, apparently knew about this, and prescribed these patches.I have ripped my shirt off screaming, asking people, “what is biting me right now”…..its around the scar area, not on the scar.Why does this happen?

    I ended up also using the other 2, (3 per day, 12 hours on, 12 off) on the tendonosis, my left leg started in with. It was tremendous pain, across my thigh, the entire groin area, down my left shin, and my hip.

    Yesterday, LBP returned. Instead of taking another Oxycodone, I use these patches, and it “shuts things up” pretty quickly.

    Honestly.. except for the price, why are we not weaned onto these, more quickly?
    I believe using these could keep everyone off of opiates.
    Seems like the offices suddenly try to, drive you away so it does not become their problem.

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