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

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

Initial criteria

The requested agent will be used for ONE of the following indications: post-herpetic neuralgia (PHN) OR neuropathic pain associated with cancer or cancer treatment 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. patient has tried and had an inadequate response to over-the-counter topical lidocaine [chart notes required]

12 months