Standard Health Pals Formulary
Lidocaine 5% Topical Patch (Generic for Lidoderm)
Coverage Level – 100%
Copay – $0
Limitations – No more than 30 days’ supply; Maximum 30 patches in 30 days; Maximum 90 patches in 90 days
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – Generic for Lidoderm