Important Information about Lidoderm/Lidocaine 5% Patch Requests

Date Issued: 11/3/2016

Clinical pharmacy programs at EmblemHealth are designed to provide our members with access to quality health care services that comply with state and federal regulations. Member safety is our top priority when determining the outcomes of coverage determination requests.

Requests for Lidoderm/Lidocaine 5% patches will be approved for patients suffering from one of the following conditions:

  • Post-herpetic Neuralgia (PHN)
  • Diabetic Neuropathic pain
  • Neuropathy due to cancer

For audit purposes, supporting documentation for Lidoderm/Lidocaine 5% patch requests must be attached to the request and accompanied by the corresponding ICD-10 codes. Please note, coverage for any diagnosis not listed above will be denied.

If you have any questions, please call EmblemHealth’s Clinical Pharmacy Services at 1-877-362-5670.