Lidoderm (lidocaine patch 5%) — Blue Cross Blue Shield of Illinois

Another FDA labeled indication for the requested agent and route of administration

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 requested agent is being used to treat the cancer OR
B. Documentation shows diagnosis of stage four advanced, metastatic cancer and use for associated condition [chart notes required] AND
2. Use consistent with best practices, supported by evidence-based literature, and FDA approved OR
B. The patient is currently treated and stable on the requested agent [chart notes required] OR
C. The patient has tried and had an inadequate response to over-the-counter topical lidocaine [chart notes required]

12 months