Lidoderm

Covered Uses:	All FDA-approved indications not otherwise excluded from Part D. Additional off-label coverage is provided for diabetic neuropathy.
Exclusion Criteria:	Coverage is not provided for neuropathic pain other than postherpetic neuralgia or diabetic peripheral neuropathy (for example, radiculopathy, or chemotherapy related neuropathy).
Required Medical Information:	For the off-label use of diabetic neuropathy: the patient must have previous use and inadequate response or intolerance to any ONE neuropathic pain medication, including (but not limited to): tri-cyclic antidepressants, gabapentin, Lyrica, opioids, venlafaxine, Cymbalta.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:	12 months
Other Criteria:

Last Modified on 12/19/2012