All topical lidocaine agents (for Ohio members) — Blue Cross Blue Shield of Illinois
Indication supported by two peer-reviewed journal articles as generally safe and effective
Initial criteria
- 1. The member resides in Ohio AND
- 2. The plan is Fully Insured or HIM Shop (SG) AND
- 3. The patient does not have any FDA labeled contraindications to the requested agent AND
- 4. ONE of the following:
- i. Another FDA labeled indication OR
- ii. Compendia-supported indication OR
- iii. Two peer-reviewed journal articles supporting use (not case studies)
Approval duration
12 months