ZTlido (lidocaine topical system 1.8%) — 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 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 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 it [chart notes required] OR
• C. The patient has tried and had an inadequate response to over-the-counter topical lidocaine [chart notes required].

Approval duration

12 months