berdazimer sodium gel 10.3% — Blue Cross Blue Shield of Kansas

Initial criteria

• The patient has a diagnosis of molluscum contagiosum (MC) OR the patient has another FDA labeled indication for the requested agent
• 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 for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• The patient has ONE of the following: (1) Tried and had an inadequate response to ONE conventional therapy (e.g., cantharidin, cryotherapy, curettage, podofilox) OR (2) An intolerance or hypersensitivity to ONE conventional therapy OR (3) An FDA labeled contraindication to ALL conventional therapy OR There is support that conventional therapy is NOT recommended for the patient
• 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
• 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
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 weeks