birch triterpenes gel 10% — Blue Cross Blue Shield of New Mexico

other FDA labeled indication for the requested agent

Initial criteria

ONE of the following: A. The patient has a diagnosis of dystrophic or junctional epidermolysis bullosa confirmed by genetic testing (medical records required) OR B. The patient has another FDA labeled indication for the requested agent
If the patient has an FDA approved 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 does NOT have current evidence or a history of squamous cell carcinoma on the area to be treated
The patient does NOT have an active infection on the area to be treated
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, geneticist) 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 a gene therapy agent on the area to be treated
The patient does NOT have any FDA labeled contraindications to the requested agent

The patient has been previously approved for the requested agent through the plan’s Prior Authorization criteria
The patient has had clinical benefit with the requested agent
The patient does NOT have current evidence or a history of squamous cell carcinoma on the area to be treated
The patient does NOT have an active infection on the area to be treated
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, geneticist) 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 a gene therapy agent on the area to be treated
The patient does NOT have any FDA labeled contraindications to the requested agent

4–12 months