ZTlido (lidocaine topical system 1.8%) — Blue Cross Blue Shield of Oklahoma
Neuropathic pain associated with cancer or cancer treatment
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]
Approval duration
12 months