Pliaglis (lidocaine 7%/tetracaine cream 7%) — Blue Cross Blue Shield of New Mexico
Tried and had an inadequate response to over-the-counter topical lidocaine
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