Synera (lidocaine 70 mg/tetracaine 70 mg patch) — Blue Cross Blue Shield of Illinois

Initial criteria

• Requested agent will be used for local dermal analgesia for superficial venous access or superficial dermatological procedures OR patient has another FDA labeled indication for the requested agent and route of administration AND one of the following:
• — Prescriber has stated or submitted documentation that patient has been diagnosed with stage four advanced metastatic cancer and the requested agent is used to treat the cancer or a related condition AND use is consistent with best practices, supported by evidence, and FDA approved OR
• — Patient is currently stable on the requested agent [chart notes required] OR
• — Patient has tried and had inadequate response to over-the-counter topical lidocaine [chart notes required] OR
• — Over-the-counter topical lidocaine was discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
• — Patient has intolerance or hypersensitivity to over-the-counter topical lidocaine not expected to occur with the requested agent [chart notes required] OR
• — Patient has FDA labeled contraindication to all over-the-counter topical lidocaine not expected to occur with the requested agent [chart notes required] OR
• — Over-the-counter topical lidocaine is expected to be ineffective, cause adherence barrier, worsen comorbid condition, decrease functional ability, or cause harm [chart notes required] OR
• — Over-the-counter topical lidocaine is not in the patient's best interest based on medical necessity [chart notes required] OR
• — Patient has tried another drug in the same pharmacologic class or mechanism as over-the-counter topical lidocaine and it was discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
• — Prescriber has provided information indicating over-the-counter topical lidocaine is NOT clinically appropriate
• Patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

12 months