How do I get insurance to cover lidocaine (lidocaine hydrochloride) cream?

How to Get Insurance Coverage for Lidocaine Cream

To get insurance coverage for lidocaine cream, you need to obtain a prescription from your healthcare provider and have them document medical necessity for the specific FDA-approved indication of pain relief.

Understanding Lidocaine Cream Coverage

• Lidocaine cream formulations (such as EMLA cream, which contains lidocaine and prilocaine) are typically covered by insurance when prescribed for FDA-approved indications and documented as medically necessary 1, 2
• Insurance is more likely to cover lidocaine when prescribed for neuropathic pain conditions or for procedural pain relief rather than for cosmetic purposes 1, 3

Steps to Obtain Insurance Coverage

1. Obtain a prescription from your healthcare provider:

   • Lidocaine cream requires a prescription for insurance coverage 1
   • Even though some formulations are available over-the-counter, insurance will only cover prescription versions 4

2. Ensure proper documentation of medical necessity:

   • Your provider should document a specific medical condition that requires pain management 1
   • Documentation should specify why lidocaine cream is the appropriate treatment option 1

3. Request specific formulations:

   • EMLA cream (lidocaine-prilocaine) is more commonly covered for procedural pain relief 2, 5
   • 5% lidocaine patches may be covered for post-herpetic neuralgia or other neuropathic pain conditions 1, 3

4. Consider FDA-approved indications:

   • Insurance typically covers medications only for FDA-approved uses 1
   • For lidocaine cream, this includes relief of pain associated with:
     • Procedural pain (venipuncture, IV placement) 2
     • Post-herpetic neuralgia (for lidocaine patches) 1

Common Pitfalls to Avoid

• Using for off-label purposes: Insurance often denies coverage for off-label uses unless medical necessity is well-documented 1
• Requesting high quantities: Excessive amounts may trigger insurance review or denial 4
• Missing prior authorization: Some insurance plans require prior authorization for lidocaine formulations 1

Alternative Approaches if Coverage is Denied

• Appeal the denial: Work with your healthcare provider to submit an appeal with additional documentation of medical necessity 1
• Consider lower-cost alternatives: Some over-the-counter lidocaine formulations may be more affordable than insurance copays 4
• Ask about patient assistance programs: Some pharmaceutical companies offer assistance programs for patients without adequate coverage 1

Special Considerations

• Pediatric patients: EMLA cream is commonly covered for procedural pain in children when properly prescribed 2, 6
• Elderly patients: Coverage may be easier to obtain for neuropathic pain conditions which are more common in older adults 1
• Chronic pain patients: Long-term use requires periodic reassessment and documentation of continued need 1