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Pliaglis (lidocaine 7%/tetracaine cream 7%) — Blue Cross Blue Shield of New Mexico

Patient currently stable and being treated with the requested agent

Initial criteria

  • The requested agent will be used for one of the listed indications AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • If applicable, chart notes are required as indicated in criteria

Approval duration

12 months