lidocaine (any topical agent covered under policy) — Blue Cross Blue Shield of Texas

Any use meeting criteria for Ohio residents under fully insured or HIM Shop (SG) plan

Initial criteria

1. The member resides in Ohio.
2. The plan is Fully Insured or HIM Shop (SG).
3. The patient does NOT have any FDA labeled contraindications to the requested agent.
4. ONE of the following applies:
i. The patient has another FDA labeled indication for the requested agent and route of administration OR
ii. The patient has another indication supported in compendia for the agent and route of administration OR
iii. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use as generally safe and effective. Acceptable study designs include randomized, double-blind, placebo-controlled clinical trials.

12 months