Filsuvez (birch triterpenes gel 10%) — Blue Cross Blue Shield of Illinois

Initial criteria

• For BCBS NM Fully Insured or NM HIM member: ALL of the following:
• A. The patient does NOT have any FDA labeled contraindications to the requested agent
• B. The requested indication is a rare disease
• C. ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication supported in compendia for the requested agent and route of administration
• OR For an Ohio member (Fully Insured or HIM Shop): ALL of the following:
• A. The member resides in Ohio
• B. The plan is Fully Insured or HIM Shop (SG)
• C. The patient does NOT have any FDA labeled contraindications to the requested agent
• D. ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication supported in compendia for the requested agent and route of administration OR (3) The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use as generally safe and effective

Approval duration

12 months