Lidocaine Topical – Lidocaine 2% Gel/Jelly Prior Authorization (with Quantity Limit) Criteria - Medicare Part D

Lidocaine 2% gel, lidocaine 2% jelly, and Glydo 2% will be approved when BOTH of the following are met:

    1. The requested medication will be used for ONE of the following:

        A. Surface anesthesia and lubrication for urethral procedure

OR

        B. Topical treatment for pain of urethritis

OR

        C. Surface anesthesia and lubrication for endotracheal intubation (oral and nasal)

OR

        D. Another indication that is supported in CMS approved compendia for the requested medication

AND

    2. ONE of the following:

        A. The requested quantity (dose) does NOT exceed the program quantity limit

OR

        B. BOTH of the following:

            i. The requested quantity (dose) is greater than the program quantity limit

AND

            ii. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months