lidocaine topical ointment 5% — Blue Cross Blue Shield of Texas

Initial criteria

• 1. The requested agent will be used for ONE of the listed indications.
• 2. ONE of the following applies:
• A. BOTH of the following:
• 1. ONE of the following:
• A. The prescriber has stated that the patient has been diagnosed with stage four advanced metastatic cancer and the requested agent is being used to treat the cancer OR
• B. The prescriber has submitted documentation that the patient has been diagnosed with stage four advanced metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND
• 2. The use of the requested agent is consistent with best practices for the treatment of stage four advanced metastatic cancer or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the FDA OR
• B. The patient is currently being treated with the requested agent and is currently stable on the requested agent [chart notes required] OR
• C. The patient has tried and had an inadequate response to over-the-counter topical lidocaine [chart notes required] OR
• D. Over-the-counter topical lidocaine was discontinued due to lack of efficacy, diminished effect, or an adverse event [chart notes required] OR
• E. The patient has an intolerance or hypersensitivity to over-the-counter topical lidocaine not expected to occur with the requested agent [chart notes required] OR
• F. The patient has an FDA labeled contraindication to ALL over-the-counter topical lidocaine not expected to occur with the requested agent [chart notes required] OR
• G. Over-the-counter topical lidocaine is expected to be ineffective based on known clinical characteristics of the patient or drug, expected to cause significant barrier to care, worsen a comorbid condition, decrease functional ability, or cause adverse reaction [chart notes required] OR
• H. Over-the-counter topical lidocaine is not in the patient’s best interest based on medical necessity [chart notes required] OR
• I. The patient has tried another drug in the same pharmacologic class and it was discontinued due to lack of efficacy or an adverse event [chart notes required] OR
• J. The prescriber has provided information indicating that over-the-counter topical lidocaine is NOT clinically appropriate.
• 3. The patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

12 months