Collagenase Santyl Ointment — CareFirst (Caremark)

Initial criteria

• Authorization may be granted when the requested drug is being prescribed for debriding chronic dermal ulcers or severely burned areas.

Reauthorization criteria

• Authorization may be granted when the requested drug is being prescribed for debriding chronic dermal ulcers or severely burned areas and ALL of the following criteria are met:
• The wound has been evaluated for granulation tissue.
• Granulation tissue is NOT well established.

Approval duration

3 months