Synera (lidocaine 70 mg/tetracaine 70 mg patch) — Blue Cross Blue Shield of New Mexico
Tried another drug in same pharmacologic class with inadequate response or adverse event
Initial criteria
- The requested agent will be used for one of the listed indications AND
- The patient does NOT have any FDA labeled contraindications to the requested agent
- If applicable, chart notes are required as indicated in criteria
Approval duration
12 months