Synera (lidocaine 70 mg/tetracaine 70 mg patch) — Blue Cross Blue Shield of Texas

Initial criteria

• Patient has no FDA labeled contraindications to the requested agent AND ONE of the following:
• - Patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to the cancer (chart notes required) AND the use is consistent with best practices, supported by peer-reviewed, evidence-based literature, and FDA-approved OR
• - Patient is currently being treated with and stable on the requested agent (chart notes required) OR
• - Patient has tried and had an inadequate response to over-the-counter topical lidocaine (chart notes required) OR
• - Over-the-counter topical lidocaine was discontinued due to lack of efficacy, effectiveness, diminished effect, or adverse event (chart notes required) OR
• - Patient has intolerance or hypersensitivity to over-the-counter topical lidocaine not expected to occur with the requested agent (chart notes required) OR
• - 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
• - Over-the-counter topical lidocaine expected to be ineffective based on clinical characteristics, cause adherence barrier, worsen comorbid condition, impair function, or cause harm (chart notes required) OR
• - Over-the-counter topical lidocaine not in the best medical interest (chart notes required) OR
• - Patient has tried another drug in same pharmacologic class or mechanism as over-the-counter topical lidocaine that was discontinued due to lack of efficacy/effectiveness/diminished effect/adverse event (chart notes required) OR
• - Prescriber has provided information that indicates over-the-counter topical lidocaine is not clinically appropriate

Approval duration

12 months