Pliaglis (lidocaine 7%/tetracaine cream 7%) — Blue Cross Blue Shield of Oklahoma

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 for cancer-related use: documentation that the patient has stage four advanced metastatic cancer and the requested agent is used to treat the cancer or an associated condition AND the use is consistent with best practices and FDA approval
• OR the patient is currently stable on the requested agent [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 or effectiveness, diminished effect, or an adverse event [chart notes required]
• OR the patient has 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 to occur with the requested agent [chart notes required]
• OR over-the-counter topical lidocaine is expected to be ineffective based on known clinical characteristics, to cause adherence issues, to worsen comorbidity, to impair function, or to cause harm [chart notes required]
• OR over-the-counter topical lidocaine is not in the best interest of the patient based on medical necessity [chart notes required]
• OR the patient has tried another drug in same pharmacologic class or mechanism as OTC topical lidocaine that failed or caused adverse event [chart notes required]
• OR the prescriber provides rationale that OTC topical lidocaine is not clinically appropriate

Reauthorization criteria

• Patient continues to meet initial criteria and remains stable on therapy

Approval duration

12 months