Lidocaine Patch Not Covered by Part D

Is your Lidocaine patch not covered by your Medicare drug plan?  Medicare seems to be cracking down on drugs that are prescribed for “off label” usage.  I got an email from a client who has been using the Lidocaine Patch for years – and now she’s being told her Medicare Advantage plan won’t pay for it.

Why, all of a sudden, is the Lidocaine patch not covered by Part D?

Shirley is in her 80’s and has severe back pain due to scoliosis.  She has tried other pain medications, but they did not help – and they affected her balance. The Lidocaine patch has given her relief and it has been covered by her Medicare Advantage plan’s Part D – until recently.

Shirley was enrolled with Health Net for several years and the Lidocaine patch was covered.  She changed to Blue Cross Blue Shield of Arizona Advantage and they say they can’t pay for this prescription.

I checked with CMS (Centers for Medicare and Medicaid Services) and a pharmacy specialist got me the answer:  The Lidocaine patch is prescribed for only one condition, post-herpetic neuralgia, which is a complication from shingles. That is the only usage for which her Part D plan can pay for the patch.

The following is from Chapter 6 of the Medicare Prescription drug manual regarding the use of drugs and the need for FDA indication or compendia listing.

http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter6.pdf

Part D sponsors are responsible for ensuring that covered Part D drugs are prescribed for “medically-accepted indications.” Part D sponsors may rely on utilization management policies and procedures to make such determinations but pharmacists are not required to contact each prescriber to verify whether a prescription is being used for other than a medically-accepted indication.

The CMS pharmacy specialist said Shirley should appeal the denial, but she might not be happy with the final decision.

I don’t know if BCBS of AZ Advantage is following the Medicare rules more closely than Health Net did, or if Medicare is cracking down and requiring plans to follow the rules.  Either way, Shirley is in a tough situation because she has gotten relief from her pain by using the Lidocaine patch  – and now she won’t get that relief.

What Next?

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39 Responses to "Lidocaine Patch Not Covered by Part D"

  1. Amy Steele says:

    Hi Denise,

    I’m glad you posted to FB. It reminded me that I want to read your blog!!

    When you get time, I’d like to talk about changing to an HMO for next year. BTW, I don’t use the ASRS insurance, so that is not an issue.

    My PCP will take BC/BS of AZ and just about all advantage plans. I think I still want to keep the secondary also. I do like having no copay with AARP, but I’m open to your thoughts.

    As I said, no rush. Just whenever you have some time.

    Take care……Amy

  2. Albert Luongo says:

    Lidoderm 5% (generic lidocaine 5%) patch is very expensive medication which though very helpful and safer than most inexpensive oral pain medications, does not decrease mortality. Because the government is looking to decrease costs, medications used off label are easy targets to cut from medicare (and soon to be Medicaid) coverage. A new OTC, relatively inexpensive product called Nordic ICE Pain Relief gel by Nordic Therapeutics may provide effective relief for pain usually treated by Lidocaine/Lidoderm 5% patches. Sold on Amazon.com..
    Albert Luongo, PA-C
    AMI Surgery

  3. Well, likely other payers of the prescription patches Lidocaine 5% and Flector will follow suit. An OTC product called Nordic ICE Pain Relief gel apparently
    Is as efficacious as these patches at a fraction of the cost. They may even work better because there is
    nordic can be applied to flexor surfaces and joints such as the hands and feet. It is sold at Indpendent pharmacies and on Amazon.com without a prescription. Safer than narcotics or NSAIDs.

    Albert Luongo, MS, PA-C, MBA

  4. Jackie
    Sorry about your back pain and medication expense (Lidocaine 5% patches). There is a new OTC pain gel/cream called Nordic ICE Pain Relief Gel that
    May be a good substitute which contains Lidocaine and Arnica, at a cost of about $37 per jar. Can get it on Amazon.
    Good Luck. Hope you find relief from your pain.
    Albert NY
    Good L

  5. Eric Paquin says:

    There seems to be several people claiming to be people they aren’t in the comments here. Look at them closely. They are almost all worded the same for the same product. Any ways. There are many topical creams and lotions in the market that may or may not work. If your trying things I had a provider tell me orajel for your mouth will also work for some on their skin for other pain. I am in the same boat as many. The patches helped a lot with my lower back pain however my prior authorization expired and now can’t get them. I will be seeking to see if part b will cover them. Just a thought.

  6. Eric Paquin says:

    Sadly no. If Medicare doesn’t cover something most times Medicaid will not either. They typically follow that line of thinking. Same would happen if your dr wanted you on vitamins. Under medicaid they are covered however if you have both (like I do too) they aren’t. stinks but that’s the facts. You can look up CMS rules and this will tell you the same thing. That’s what they go by. There are a few exceptions but they are few and far between that I’ve found. Wish you lots of luck. Then next thing I am going to try is getting it covered via diabetic neuropathy. As I have both issues it might be a work around but we will see what other road blocks they throw up.

  7. Michael L. Snodgrass says:

    I suffer with severe osteoarthritis in both knees especially throughout the night. ONLY a strip of Lidocaine 5% patch placed below the kneecaps gave me any relief. My Blue Advantage plan is denying this script but was kind enough to supply the appeal process and in the waiting time leaving me in all night excruciating pain. Again, I have tried many other products and the Lidocaine 5% patch is the only product that gave any relief.

  8. Albert Luongo says:

    Helpful hint when looking for topical pain relievers:
    The very inexpensive products generally contain only menthol at high doses (over 4%), and or topical emollients and fillers which do not add to pain relief. (Examples of non effective ingredients: aloe, vitamins, various oils, etc). Combination, higher end OTC products containing lidocaine (over 3%) PLUS ingredients such as menthol/camphor will generally work MUCH better (synergistically), than the low end, bargain prices products (lidocaine without other synergistic ingredients. Added ingredients such as Methyl salicylate or Arnica Montana help to decrease inflammation when COMBINED). Questionable whether MSM or glucosamine are effective when used topically. Although a large molecule, too bag ibuprofen or naproxen sodium is not allowed by the FDA to use as a topical as it is in other countries. A topical cream product containing ibuprofen was removed from the market a few years ago after multiple warning letters sent to the manufacturer from the FDA. Nordic ICE pain gel may be as effective as some prescription topicals such as diclofenac or lidocaine 5%.

  9. Cynthia Manca says:

    I too have been using Lidocaine patches for years since I’ve run the course at the Pain Management doctors office. Having gone through back injections and ablation, which didn’t help with lower back pain. I am 63 and am on disability for many years, due to Lupus & Fibromyalgia. I have widespread arthritis & it often appears in my lower back. I am blown away that Medicare has decided not to cover these patches, which have given me some relief from pain, without taking a harsh narcotic. Medicare will cover my prescription for Norco (oxy & tylenol) for pain (which I take so I don’t have to go to ER for pain) but not Lidocaine patches. This make NO sense!

  10. Very efficiently written information. It will be valuable to everyone who uses it, including myself. Thanks a lot

  11. Albert Luongo says:

    Shirley in her 80’s – because Medicare part D will no longer cover her off label use of the Lidocaine 5% patch will likely receive pain medication with multiple potential side effects such as constipation, dizziness, GI issues or medicine interactions. This example will likely increase Mediare’s overall costs with more clinician visits for side effect and other pain management modalities. Too bad, she was doing fine on a relatively safe and effective medication. There is an effective OTC that may help called Nordic ICE anti-pain gel seldom Amazon.com

    Albert Luongo, PA-C, MBA

  12. Linda says:

    My husband uses the patch also. I do not know why Medicare wants to stop paying for them, so many people use them, and they are safer then the pill.

  13. Anne says:

    GOT IT WRONG!!! The Medically-accepted crap is another way to say “Meets diagnostic criteria” and is a new way for Part D’s to deny an expensive drug

    OH NO!! AN INSURANCE COMPANY MISBEHAVING!?!?! SAY IT ISN’T SO!

    They pulled this stunt with me in 2013-14 and I got that company under CMS audit for 6 months and they screwed up so bad while being watched they lost their part D certification for a year!!

    The MEDICARE/FDA DIAGNOSTIC CRITERIA FOR LIDODERM is PAIN. And diagnosis with the word pain in it.

    FDA APPROVED THE USE OF LIDODERM FOR TOPICAL USE IN 2004.
    FOR USE OUTPATIENT 2004
    For neuropathic pain (extremities) 2004
    For back pain 2004
    For all external pain 2004

  14. Regarding Medicare part D and Lidocaine 5% patches: As far as I can tell, the patches are only indicated presently for Post Herpetic Neuralgia pain. Any another pain is off label usage. While it is unfortunate that The lidocaine patches no longer being covered, they are expensive and Mediacare has limited funds for medications. There are Over the counter lidocaine 4% patches (though delivery system is not quite as sophisticated as with the prescription patches) and gels and creams containing 3-4% lidocaine. One more affirdable product called Nordic ICE Pain Relief gel: contains 3.5% lidocaine plus other ingredients enhancing the pain relief effect of the lidocaine – which I regularly suggest to my patients. Very effective alternative. It can be found on Amazon.com…

  15. Sally Thomas says:

    I, also, have been using Lidocaine 5% patches for muscle seizure pain in my back due to Scoliosis. First RX was in 2014 for a 90 day supply. I cut the patches into small patches and used them very sparingly. The WORK! Nothing else works. Not Aspercream, Solonpas (pathes, gels, spray), not Tiger Balm (patches, gel) none of the OTC products. I had to change doctor in late 2014, but I was so frugal with the patches that I only recently ran out. Now, I am in constant pain, cannot complete my housework or grocery shopping, stay home all of time due to pain, because even though I tried to get a refill from the same pharmacy that filled the original prescription, they said they needed that dreaded “Prior Authorization”, which they promptly denied for the reasons the other posters here have also received. I still meet people who are still able to obtain an approval for the patches from Medicare that have the very same pain issue that I do. The I don”t understand as Medicare will approve a plethora of oral “pain pills” that zonk you out, put strain on your liver and kidnies and who knows what else? Also, I am subject to blood clots in my legs if I do a lot of bed rest…well guess what the pain meds do? Yep, make you drowzy. Also, the back pain gets so bad at time I have to lie down whether I want to or not. Example: right now I am blanching vegetables to freeze. My back muscles are seizing so badly and so painfully that I cannot complete the job until I lie down for an hour or two. I am an active *until this back thing) 74 year old rancher and used to hard work. Now it seem Medicare is simply wanting us to roll over and die rather than allow medications that WORK for us to be prescribed. I have gone through 4 appeals (which were decided within a day of submission) and the last one for “independent review) was returned yesterday, within my FAXing of it just Wednesday…again a DENIAL. They still claim their “formulary” does not allow it except for terminal cancer or shingles. This is all BS considering they are SELECTIVELY allowing it here and there. I am going to keep appealing for as long as there is one allowed.

  16. Janet says:

    I m plenty disgusted with Medicare D! They have taken away the right of the doctors to use their discretion for their patients! I have denied 4 medications this month, one because I am over 65! Bunch of cheapskate politians robbing the elderly. They don’t worry cause they have money!

  17. Linda says:

    That is bull, my husband has bone cancer, and he broke his neck in 2007, and because of the cancer they had to wire he neck, so he is in a lot of pain. He need these patches to relieve some of the pain in his neck.

  18. Linda says:

    That is bull, my husband has bone cancer, and he broke his neck in 2007, and because of the cancer they had to wire he neck, so he is in a lot of pain. He need these patches to relieve some of the pain in his neck.

  19. Cynthia Manca says:

    The Obama administration has said that because so many patients seek treatment for pain, they have the right to give feedback on how it was addressed. “I know that management of pain during a hospitalization is one of the most important concerns for patients and their families,” said Dr. Kate Goodrich, a practicing doctor who oversees the federal government’s hospital quality care program.

    http://www.nytimes.com/2016/08/05/health/pain-treatment-hospitals-emergency-rooms-surveys.html?emc=edit_th_20160805&nl=todaysheadlines&nlid=60544478&_r=0

  20. Orene J Morin says:

    I am a recently retired nurse with fairly severe osteoarthritis in my back. I don’t want to or like to take oral pain meds. The Lidocaine patches allowed me to work, until retirement.
    Boom! Sign up for Medicare, 3 appeals by 2 MSs, and the same response about not prescribing for off label. This floored me, because as a nurse, I witnessed thousands of patients, including myself, with various muscular skeletal, nerve issues since they came out.
    I have literally aged over 10 us in less than a year. Too much pain to exercise, can barely get out of bed. I am…was…an extremely active person. My big question is: HOW DOES ONE GO ABOUT CONTACTING DRUG COMPANIES TO ADD TO THEIR ON LABEL USE???
    My life is literally going down the tubes now. My entire retirement plan, much travel with my husband, is out the window.
    Thanks to Medicare part D, the golden years, have become the years from Hell.
    Does ANYBODY know about beginning this label change thing?
    Any information will be forever greatly appreciated. Thank you so much.

  21. Eric Paquin says:

    Orene J Morin I found this for your reading enjoyment. I know its more than slightly techincal but even still I believe the vast majority can get thru it. However if anyone has questions on the article I will reply with answers as I understand them from this article. I have yet to have these approved under any dx as yet. I also had to change drs and thus no longer even get to try with a specialists help. My GP has decided to try some other things rather than going the wrong way of a one way road that ends in a dead end. Hence this is no longer an issue for me. Its not as good on an option but having no other choice that’s what I am doing. Hear’s to good reading. LoL

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538391/

  22. Karen says:

    Has anyone tried Aspercreme 4% Lidocaine Pain Relief Patch? My Dad has the same issue. The Lidocaine 5% patch seems to give him a little relief at night but is not covered. He paid for 30 patches himself at $105.00 but would like to find something a little more reasonable. The Aspercreme 4% Lidocain patch is $8.00 for a box of 5. Would love to hear your experience with this product. Thank you so much!

  23. Aspercream with Lidocaine is only lidocaine 4% cream. Unless using it for sunburn, or mild itch, My patients and I do not find it very effective for any type of pain. There are other products on the web and on Amazon.com which CONTAIN lidocaine as part of a synergistic formula which Are EFFECTIVE for topical nerve and joint pain. Unlike the majority of the under $15 topical products, these are formulated to be effective and not just as a placebo. (Read about placebo effect).

    Good Luck
    Albert
    Aluongo@NordicICEgel.com

  24. Karen says:

    Thank you Albert!

    What I don’t understand is since the 5% lidocaine prescription patch helps quite a bit, why is a patch with 4% lidocaine so much less effective?I assume that 4% is the cutoff for prescription vs non-prescription. Does 1% make that much difference?

    Has anyone had good results with NordicICE…that Albert refers to? I don’t find it as a patch, just gel.

    Thanks!

  25. There are multiple brands of patches on the market that contain 4% lidocaine. Unfortunately none appear to be nearly as efficacious (for Pain relief), as the prescription Lidocaine 5% or Lidoderm 5% patches – according the experiences of my patients. I do
    not believe this is because of the 1% (20%) difference in medication as because of the
    patented, expensive patch matrix and complex delivery system and proprietary combination of inactive ingredients..which likely can’t be replicated for less than $1.00 per patch!
    The adhesive property also appear to be weaker with the OTC bargain priced patches.
    I suggest my patients (who don’t wish to take or continue narcotic pain pills), they purchase a higher end OTC pain gel/cream containing 3-4% lidocaine and apply often. Alternaively, under the guidance of an experienced clinician, or pharmacist, cover with an occlusive dressing, and change twice daily.
    Hope this helps.

    Albert A.Luongo, MS, PA-C, MBA
    Aluongo@NordicICEgel.com

  26. Orene J Morin says:

    The Aspercream Lidocaine patches have a different mechanism of delivery than the prescrcription patch, which is unfortunately not available on Medicare, for we that have needed them to get through a fairly normal life.
    I did buy 2 boxed otc of the aspercream patches…they were buy one get one 50% off.
    I received minimal, if any relief at all.

  27. Sorry to hear the OTC patches don’t help but not suprised. It’s difficult to create an effective lidocaine patch with an actual delivery system for $1.00 or less per patch. Though pricey, the Lidoderm 5% patches and lidocaine patches are expensive to manufacture, test, and patent. Alternatively to bypass any patch delivery system, purchase a High end OTC topical cream or gel with 3-4 % lidocaine as ONE of the ingredients and discuss with healthcare provider or pharmacist buying an occlusive dressing, cover the gel, and re-apply twice daily.
    Hope this helps.
    ALUONGO@NordicICEgel.com

  28. Hi. Unfortunately OTC lidocaine 4% patches are NOT (nearly) as effective as the prescription 5% Lidocaine patches. This is not because the medication is not as strong, but the matrix and delivery system are VERY different. It’s almost impossible to create a patch as effective as the precription lidocaine patches for under or even close to a dollar per patch. Option?…,Purchase a 3-4% OTC lidocaine gel or cream branded formula and ask your pharmacist or medical provider if covering the gel/cream with occlusive dressing is ok for you. Perform this twice daily under direction of your doctor or health care provider. Hope this helps.
    Albert A. Luongo, MS, PA, MBA

  29. Orene J Morin says:

    This sounds like a very good idea in the mean time. Will do.
    Thank you so much for your input.

  30. Glen McKendree says:

    It’s a crying shame in this country that insurance companies can control what doctors say is needed for their patients. I wish each and everyone would have to go through at least one month of chronic pain that some of these patients have to go through it most would jump off the bridge.

  31. Orene J Morin says:

    I just got the new med formulary for 2017 from my part D Which works in conjunction with the med policy I had at my last job…It was not on the 2016 formulary.( Lidocaine). I called my co., and they believe it may be covered after Jan. 1, 2017, with my combo Commonwealth of MA / part D policy.
    I had been on the Lidocaine patches for about 10 us since I retired about a yr and a half ago. They said it would not cover off label, last year, which is only for Shingles,( post hepatic neuropathy). Made absolutely no sense. Seeing it on the new formulary gave me some hope, except nobody in the office could give me a definitive answer. Fingers crossed!!

  32. Carol Voge says:

    People, please! Albert Luongo is a phony shilling for his product
    On Amazon! He posts much the
    same letter over & over I intend to see what Canadian pharmacies
    Charge for lidocaine patches!

    In the meantime, Medicare will be paying for an ER visit for a single patch but I am in real agony; with FMS osteoporosis, CMV, etc I can’t afford to fall but I have done and in soaked!

    Pain makes us agree to try smoking a rug if we can
    Have some pain relief but watch out for the Alberts preying
    On vulnerable people! OK? Cause of you listen to
    Charlatans you can’t really complain! So don’t!

    I am an old hand in this area having been disabled lifelong without
    Knowing it! Read “Albert’s” advice carefully! He is touting you off
    Anything but his brand! Big No No, Albert! That can cause harm!

    Pain

  33. Carla says:

    Also found this on the FDA Website. Guess this is one of the reasons for the crackdown, though this is not the brand I’ve used. Question: How do we lobby the FDA to do studies or whatever they need to do to APPROVE other, varied appropriate uses?!!

    https://www.fda.gov/ICECI/CriminalInvestigations/ucm387029.htm

  34. Sheila says:

    guess what, I’m not covered anymore either. I have Medicare, Life Script, M.A. I used to be covered but now I’m not. the patches, 2 boxes of 30, used to last me a year. I used them when I was in the hospital when i had double knee replacement; I used them for my severe muscle spasms in my back, due to the Osteoarthritis in my spine. Also get pinched nerves from the DDD, due to the OA, in the same spot; also, have spondylolisthesis, and Sacroiliitis, which started it all after I got hurt at work. I went to “M.A.P.S. (Medically Advanced Pain Specialists)” for help with my back pain, back in 2005, and was put on Gabapentin and the Lidocaine patches. both of these helped with the ‘moderate’ pain, the dr’s claim..my back causes moderate to severe muscle spasms due to the Degenerative disks. I have found Lidocaine cream, which does help, if I keep reapplying it. I use a rag, or something so I don’t get the cream on my hands. also, Salonpas has a patch with 4% Lidocaine, I have tried this, and it says it lasts an hour. I was prescribed up to 2-patches a day. I think we should have a revolt against the denial of the patches. I don’t know about you, but I need them.

  35. Sheila says:

    I have been experiencing severe back pain today. I have used my Inversion table, and heard my back crack as I stretched, give a little relief; then I moved to my bed, laying face down over it and relaxed (best I could) and that helped a little; then, I moved to my swivel chair and tried to relax. Again, severe back pain. I ran to my cupboard and looked for a patch, and found the last 1 of lidocaine, I opened the envelope, cut it in half, put the half on my back..and it was instant relief. I put the other half back in the envelope, but I will have to use it soon. I am going to a Walmart on Friday, and I must get several boxes of the Salonpas Lidocaine patches. They are very expensive. our little town doesn’t have them. They only carry the patches with Menthoyl, which stinks and warms up the area its used on. I need the cooling.

  36. EULA BULLION says:

    HAVE BEEN USING THESE PATCHES ,JUST WHEN I NEED THEM ,FOR SEVERAL YEA RS .WHY DOES OUR INSURANCE NOT HELP PAY FOR THEM, WHEN YOU CAN GO TO ANY DRUG EST AND BUY THEM , i think they just want more money from the patients they are much more expensive this way. back pain is hard to deal with without some kind of meds.which doesnt mean we are addicts., we just have back problems.

  37. EULA BULLION says:

    this is a sad thing for us.

  38. Erik says:

    I work for a pharmacy that accepts part D for Lidocaine and other prescription topical creams/patches. Please call 727-479-4995.

    Best regards,

    Erik

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