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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

January 2017

Reminder: Lidocaine Patch Coverage for Medicare Advantage Members


As a reminder, Harvard Pilgrim covers lidocaine patches for our StrideSM (HMO) Medicare Advantage members, with prior authorization, for the treatment of FDA-approved or medically accepted indications. The Centers for Medicare and Medicaid Services (CMS) expects Medicare Part D prescription drug benefit plans, such as Harvard Pilgrim’s Stride plans, to be responsible for implementing measures that ensure that Part D drugs are prescribed and utilized according to CMS regulations.

Use of lidocaine patches must be for an FDA-approved indication or supported by citations in one or more of the following compendia to qualify for coverage under Part D:

  • American Hospital Formulary Service Drug Information (AHSF-DI)
  • DRUGDEX Information System
  • United States Pharmacopeia-Drug Information (or its successor publications)

Harvard Pilgrim covers the use of lidocaine patches for the following indications only:

  • Relief of pain associated with post-herpetic neuralgia
  • Diabetic neuropathy
  • Burn pain
  • Cancer pain
  • Topical local anesthesia
In keeping with CMS regulations, lidocaine patches are not covered for any indications not listed above (for example, chronic lower back pain) under Harvard Pilgrim’s Stride (HMO) Medicare Advantage plans.

To request prior authorization for the coverage of lidocaine patches, please fill out our Medicare Prescription Drug Determination Request Form and send it by fax to 888-807-6643, or by mail to:

MedImpact Healthcare Systems, Inc.
Attn: Prior Authorization Department
10181 Scripps Gateway Court
San Diego, CA 92131

For more information, refer to Harvard Pilgrim’s Prior Authorization Criteria for Medicare Advantage plans.

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