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

Initial criteria

• The patient has a diagnosis of molluscum contagiosum (MC)
• 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
• ONE of the following: (A) BOTH of the following: (1) ONE of the following: (A) The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR (B) The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced, metastatic cancer [chart notes required]; AND (2) The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the United States Food and Drug Administration 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
• 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

6 months (BCBSMT)