lidocaine topical ointment 5% — Blue Cross Blue Shield of New Mexico

Initial criteria

• The requested agent will be used for one of the listed indications AND
• ONE of the following:
• A. The prescriber has stated or documented that the patient has stage four advanced, metastatic cancer and the requested agent is being used to treat that cancer or a related condition AND the use is consistent with best practices and peer-reviewed literature, and FDA approved OR
• B. The patient is currently being treated with the requested agent and is stable on it [chart notes required] OR
• C. The patient has tried and had an inadequate response to over-the-counter topical lidocaine [chart notes required] OR
• D. Over-the-counter topical lidocaine was discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
• E. The patient has an intolerance or hypersensitivity to over-the-counter topical lidocaine not expected to occur with the requested agent [chart notes required] OR
• F. The patient has an FDA labeled contraindication to all over-the-counter topical lidocaine not expected to occur with the requested agent [chart notes required] OR
• G. Over-the-counter topical lidocaine is expected to be ineffective, cause a barrier to adherence or worsen comorbid condition, decrease functioning, or cause adverse reaction or harm [chart notes required] OR
• H. Over-the-counter topical lidocaine is not in the best interest of the patient based on medical necessity [chart notes required] OR
• I. The patient has tried another drug in the same pharmacologic class or mechanism as over-the-counter topical lidocaine that was discontinued due to lack of efficacy or adverse event [chart notes required] OR
• J. The prescriber has provided information that indicates over-the-counter topical lidocaine is NOT clinically appropriate AND
• The patient does not have any FDA labeled contraindications to the requested agent

Approval duration

12 months