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:
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.
- Relief of pain associated with post-herpetic neuralgia
- Diabetic neuropathy
- Burn pain
- Cancer pain
- Topical local anesthesia
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.