Zelsuvmi (berdazimer sodium gel) — Blue Cross Blue Shield of Alabama

molluscum contagiosum (MC)

Initial criteria

The patient has a diagnosis of molluscum contagiosum (MC)
AND If the patient has an FDA labeled indication, then ONE of the following:
• The patient’s age is within FDA labeling for the requested indication for the requested agent OR
• There is support for using the requested agent for the patient’s age for the requested indication
AND ONE of the following:
• The patient has tried and had an inadequate response to a conventional therapy (e.g., cantharidin, cryotherapy, curettage, podofilox) OR
• The patient has an intolerance or hypersensitivity to a conventional therapy OR
• The patient has an FDA labeled contraindication to ALL conventional therapy OR
• There is support that conventional therapy is not recommended for the patient
AND The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
AND The patient will NOT be using the requested agent in combination with another conventional therapy (e.g., cantharidin, cryotherapy, curettage, podofilox) for the requested indication
AND The patient does NOT have any FDA labeled contraindications to the requested agent

12 weeks