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

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

Approval duration

12 months