lidocaine topical ointment 5% — Blue Cross Blue Shield of Oklahoma

Initial criteria

• The requested agent will be used for one of the listed indications AND
• ONE of the following:
• • The prescriber has stated or documented that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer or an associated condition AND the use is consistent with best practices supported by peer-reviewed, evidence-based literature and is FDA approved OR
• • The patient is currently being treated with the requested agent and is currently stable on it [chart notes required] OR
• • The patient has tried and had an inadequate response to over-the-counter topical lidocaine [chart notes required] OR
• • Over-the-counter topical lidocaine was discontinued due to lack of efficacy, diminished effect, or an adverse event [chart notes required] OR
• • The patient has an intolerance or hypersensitivity to over-the-counter topical lidocaine not expected with the requested agent [chart notes required] OR
• • The patient has an FDA labeled contraindication to all over-the-counter topical lidocaine not expected with the requested agent [chart notes required] OR
• • Over-the-counter topical lidocaine is expected to be ineffective, cause adherence barriers, worsen a comorbidity, reduce functional ability, or cause harm [chart notes required] OR
• • Over-the-counter topical lidocaine is not in the patient's best interest based on medical necessity [chart notes required] OR
• • The patient has tried another drug in the same pharmacologic class or mechanism of action and it was discontinued due to lack of efficacy or adverse event [chart notes required] OR
• • The prescriber has indicated 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