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.

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