ZTlido (lidocaine topical system 1.8%) — Blue Cross Blue Shield of New Mexico
Pain associated with post-herpetic neuralgia (PHN)
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]
Approval duration
12 months