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

Initial criteria

• ONE of the following indications is met: anesthesia of accessible mucous membranes of the oropharynx OR anesthetic lubricant for intubation OR pain associated with minor burns, including sunburn, abrasions of the skin, and insect bites OR another FDA labeled indication for the requested agent and route of administration
• AND ONE of the following:
• A. BOTH of the following: (1) patient has stage four advanced metastatic cancer and agent used to treat cancer OR associated condition [chart notes required]; AND (2) use consistent with best practices, supported by peer-reviewed evidence, FDA approved OR
• B. patient currently treated and stable on requested agent [chart notes required] OR
• C. tried and had inadequate response to over-the-counter topical lidocaine [chart notes required] OR
• D. discontinued OTC topical lidocaine due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required] OR
• E. intolerance or hypersensitivity to OTC topical lidocaine not expected to recur with requested agent [chart notes required] OR
• F. FDA labeled contraindication to ALL OTC topical lidocaine not expected to occur with requested agent [chart notes required] OR
• G. OTC topical lidocaine expected to be ineffective based on clinical characteristics, cause barrier to adherence, worsen comorbid condition, decrease functional ability, 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 class or mechanism as OTC topical lidocaine and discontinued due to lack of efficacy/effectiveness or adverse event [chart notes required] OR
• J. prescriber provided information that OTC topical lidocaine is NOT clinically appropriate
• AND patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months