Filsuvez — Blue Cross Blue Shield of Texas

Initial criteria

• Diagnosis of dystrophic or junctional epidermolysis bullosa confirmed by genetic testing (medical records required) OR patient has another FDA labeled indication for the requested agent
• If FDA approved indication, then patient's age is within FDA labeling OR support exists for using the agent for the patient’s age
• Patient does NOT have current evidence or history of squamous cell carcinoma on the area to be treated
• Patient does NOT have an active infection on the area to be treated
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, geneticist) or has consulted with such specialist
• Patient will NOT be using the requested agent in combination with a gene therapy agent on the area to be treated
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

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

Approval duration

12 months (BCBSIL & BCBSMT); 4 months (all others)