Lidocaine 5% ointment — Highmark

Initial criteria

• Member is using the product for anesthesia of accessible mucous membranes of the oropharynx (ICD-10 R20.0) OR as an anesthetic lubricant for intubation OR for temporary relief of pain associated with minor burns, including sunburn, abrasions of the skin, and insect bites.

Approval duration

3 months