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Drug Category: Dermatological Agents

Medication Class/Individual Agents: Local Anesthetics

I. Prior-Authorization Requirements

 Topical Anesthetics

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

capsaicin high dose patch Qutenza ^ PA  
lidocaine / prilocaine test  
lidocaine / tetracaine Synera PA   - > 4 patches / month
lidocaine 1.8% patch Ztlido PA  
lidocaine 5% patch Lidoderm # PA   - > 90 patches/month
lidocaine ointment PA  
lidocaine powder PA  
lidocaine powder intradermal injection system Zingo PA  
lidocaine viscous solution test  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

 

  • Lidocaine/prilocaine is indicated as a topical anesthetic on normal intact skin for local analgesia and on genital mucous membranes for superficial minor surgery and pre-treatment for infiltration anesthesia.
  • Lidocaine/tetracaine is indicated for use on intact skin to provide local dermal analgesia for superficial venous access and prior to superficial dermatological procedures such as excision, electrodessication, and shave biopsy of skin lesions.
  • Lidocaine/prilocaine and lidocaine/tetracaine may have improved dermal analgesia compared to other topical lidocaine products due to their eutectic mixture formulations. However, these agents are indicated only as short term anesthesia and should not be used chronically.
  • Lidocaine powder intradermal injection system is indicated for use on intact skin to provide local analgesia prior to venipuncture or peripheral intravenous cannulation in children three-to-18 years of age. This agent is also indicated for use on intact skin to provide local analgesia before venipuncture in adults.
 
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
^ This drug is available through the health care professional who administers the drug. MassHealth does not pay for this drug to be dispensed through a retail pharmacy.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Dermatological procedure requiring local analgesia (lidocaine/prilocaine, Synera)
  • Local analgesia before venipuncture or intravenous cannulation (Zingo)
  • Pain associated with post-herpetic neuralgia (lidocaine patch, Qutenza, Ztlido)
  • Surface anesthesia and temporary pain relief (lidocaine ointment)

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

  

lidocaine 5% ointment

  • Documentation of all the following is required:
    • appropriate diagnosis; and
    • medical necessity for the requested product.

  

lidocaine 5% patch > 90 patches/month

  • Documentation of all the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of > 90 patches/30 days.

  

lidocaine powder

  • Documentation of all the following is required:
    • appropriate diagnosis; and
    • clinical rationale why other commercially available alternatives cannot be used.

  

lidocaine/prilocaine

  • Does not require PA. However, requests for members with a diagnosis code for premature ejaculation will deny at the pharmacy as PA required.
  • Please note: The MassHealth agency does not pay for any drug when used for the treatment of male or female sexual dysfunction as described in 130 CMR 406.413(B) “Limitations on Coverage of Drugs – Drug Exclusions” (see link below).

https://www.mass.gov/regulations/130-CMR-406000-pharmacy-services

  

Qutenza

  • Documentation of all the following is required:
    • diagnosis of post-herpetic neuralgia; and
    • inadequate response, adverse reaction, or contraindication to lidocaine patch; and
    • inadequate response, adverse reaction, or contraindication to a topical capsaicin agent; and
    • one of the following:
      • medical necessity for transdermal formulation; or
      • inadequate response, adverse reaction, or contraindication to both of the following classes of oral agents:
        • tricyclic antidepressant; and
        • anticonvulsant (gabapentin at a dose of at least 1,200 mg/day for two weeks, or pregabalin).

  

Synera

  • Documentation of all the following is required:
    • diagnosis of a procedure requiring local analgesia; and
    • medical necessity for exceeding 4 patches/month.

SmartPA: Claims for Synera (lidocaine/tetracaine) for > 4 patches/month and ≤ 12 patches/month will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for a diagnosis code for end-stage renal disease requiring dialysis.

  

Zingo

  • Documentation of all the following is required:
    • diagnosis of local analgesia prior to venipuncture or intravenous cannulation; and
    • member is ≥ three years of age; and
    • inadequate response, adverse reaction, or contraindication to Synera (lidocaine/tetracaine); and
    • one of the following:
      • request is for ≤ 12 units per month; or
      • medical necessity for > 12 units per month.

 

Ztlido

  • Documentation of all the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to 5% lidocaine patch; and
    • one of the following:
      • request is for ≤ 90 patches per 30 days; or
      • medical necessity for > 90 patches per 30 days.

  

Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 03/2012

Last Revised Date: 08/2019


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Last updated 11/15/19