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

Initial criteria

• The requested agent will be used for an FDA-labeled indication OR one supported in compendia OR the prescriber has provided two peer-reviewed journal articles supporting the proposed use
• The patient does NOT have any FDA labeled contraindications to the requested agent
• AND ONE of the following:
• • Patient currently being treated and stable on requested agent [chart notes required]
• • Patient tried and had inadequate response to over-the-counter topical lidocaine [chart notes required]
• • Over-the-counter topical lidocaine discontinued due to lack of efficacy or adverse event [chart notes required]
• • Patient has intolerance or hypersensitivity to over-the-counter topical lidocaine not expected with requested agent [chart notes required]
• • Patient has FDA labeled contraindication to ALL over-the-counter topical lidocaine not expected with requested agent [chart notes required]
• • Over-the-counter topical lidocaine expected to be ineffective or cause adherence barrier, worsen comorbid condition, decrease functional ability, or cause harm [chart notes required]
• • Over-the-counter topical lidocaine not in patient's best interest based on medical necessity [chart notes required]
• • Patient tried another prescription drug in same pharmacologic class as over-the-counter topical lidocaine which was discontinued due to lack of efficacy or adverse event [chart notes required]
• • Prescriber provided information that over-the-counter topical lidocaine is not clinically appropriate

Approval duration

12 months