lidocaine HCl 4% gel — CareFirst (Caremark)

Initial criteria

• Authorization may be granted when the requested product will NOT be used as part of a compound AND ONE of the following criteria are met:
• Lidocaine-prilocaine 2.5-2.5% cream is prescribed as a topical anesthetic for use on normal intact skin for local analgesia OR genital mucous membranes for superficial minor surgery or as pretreatment for infiltration anesthesia
• Lidocaine 5% ointment is prescribed for production of anesthesia of accessible mucous membranes of the oropharynx; as an anesthetic lubricant for intubation; or for temporary relief of pain associated with minor burns including sunburn, abrasions of the skin, or insect bites
• Lidocaine urethral/mucosal 2% gel is prescribed for prevention and control of pain in procedures involving the urethra; topical treatment of painful urethritis; or as an anesthetic lubricant for endotracheal intubation (oral or nasal)
• Lidocaine-tetracaine 7-7% cream (Pliaglis) is prescribed for use on intact skin in adults to provide topical local analgesia for superficial dermatological procedures such as dermal filler injection, pulsed dye laser therapy, facial laser resurfacing, or laser-assisted tattoo removal
• Lidocaine 4% topical solution is prescribed for the production of topical anesthesia of accessible mucous membranes of the oral or nasal cavities or proximal portions of the digestive tract
• Lidocaine-tetracaine 70-70 mg patch (Synera) is prescribed for use on intact skin to provide local dermal analgesia for superficial venous access or superficial dermatological procedures such as excision, electrodessication or shave biopsy of skin lesions
• Lidocaine 2% gel OR Lidocaine-collagen-aloe vera 2% gel is prescribed for the local management of painful skin wounds (pressure ulcers, venous stasis ulcers, superficial wounds or scrapes, 1st or 2nd degree burns) AND the patient experienced inadequate treatment response, intolerance, or contraindication to all available FDA-approved drugs and OTC products for their condition
• Lidocaine 4% gel is prescribed for Stage I–IV pressure ulcers, venous stasis ulcers, ulcerations caused by mixed vascular etiologies, diabetic skin ulcers, first or second degree burns, or post-surgical incisions, cuts or abrasions AND the patient experienced inadequate treatment response, intolerance, or contraindication to all available FDA-approved drugs and OTC products for their condition

Approval duration

3 months