Zelsuvmi — Blue Cross Blue Shield of Illinois

Initial criteria

• 1. The patient has a diagnosis of molluscum contagiosum (MC) AND
• 2. If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication OR (B) There is support for using the requested agent for the patient’s age for the requested indication AND
• 3. ONE of the following: (A) BOTH of the following: (1) The patient has stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer or an associated condition AND (2) The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer; OR (B) The patient has tried and had an inadequate response to a conventional therapy (e.g., cantharidin, cryotherapy, curettage, podofilox) OR (C) The patient has an intolerance or hypersensitivity to a conventional therapy OR (D) The patient has an FDA labeled contraindication to ALL conventional therapy OR (E) There is support that conventional therapy is not recommended for the patient AND
• 4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist) or has consulted with a specialist AND
• 5. The patient will NOT use the requested agent in combination with another conventional therapy for the requested indication AND
• 6. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

6 months or 12 weeks (plan dependent)