lidocaine topical products (general approval if member resides in Ohio) — Blue Cross Blue Shield of Montana
proposed use supported by two peer-reviewed journal articles
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
Approval duration
12 months