lidocaine topical products (general approval if member resides in Ohio) — Blue Cross Blue Shield of Montana

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

Initial criteria

Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
AND patient does NOT have any FDA labeled contraindications to the requested agent
AND ONE of the following:
patient has another FDA labeled indication for the requested agent and route of administration OR
patient has another indication supported in compendia for the requested agent and route of administration OR
prescriber submitted two peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting proposed use as generally safe and effective

12 months