lidocaine topical ointment 5% — Blue Cross Blue Shield of Illinois

Initial criteria

• 1. The requested agent will be used for one of the listed indications AND
• 2. ONE of the following:
• A. BOTH of the following:
• 1. ONE of the following:
• A. The prescriber has stated that the patient has stage four advanced, metastatic cancer and the drug is being used to treat the cancer OR
• B. Documentation shows the patient has stage four advanced, metastatic cancer and the drug is being used for an associated condition [chart notes required] AND
• 2. Use is consistent with best practices, supported by evidence-based literature, and FDA approved OR
• B. The patient is currently treated and stable on the agent [chart notes required] OR
• C. The patient has tried and had an inadequate response to over-the-counter topical lidocaine [chart notes required] OR
• D. OTC topical lidocaine discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
• E. Intolerance or hypersensitivity to OTC topical lidocaine that is not expected with requested agent [chart notes required] OR
• F. FDA labeled contraindication to all OTC topical lidocaine not expected with requested agent [chart notes required] OR
• G. OTC topical lidocaine expected to be ineffective or cause barrier to adherence, worsen condition, or cause harm [chart notes required] OR
• H. OTC topical lidocaine not in best interest of patient based on medical necessity [chart notes required] OR
• I. Tried another drug in same pharmacologic class as OTC topical lidocaine and discontinued due to lack of efficacy or adverse event [chart notes required] OR
• J. Prescriber provided information indicating OTC topical lidocaine is not clinically appropriate AND
• 3. The patient does not have any FDA labeled contraindications to the requested agent

Approval duration

12 months