topical lidocaine products (Ohio provision) — Blue Cross Blue Shield of Oklahoma

Any FDA labeled indication for the requested agent and route of administration

Initial criteria

The member resides in Ohio AND
The plan is Fully Insured or HIM Shop (SG) AND
The patient does not have any FDA labeled contraindications to the requested agent AND
ONE of the following:
• The patient has another FDA labeled indication for the requested agent and route of administration OR
• The patient has another indication supported in recognized compendia OR
• The prescriber has submitted two articles from major peer-reviewed journals supporting the use as generally safe and effective

12 months