topical lidocaine products (Ohio provision) — Blue Cross Blue Shield of Oklahoma
Other indication supported by two peer-reviewed professional journal articles demonstrating safety and efficacy
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