Filsuvez (birch triterpenes) — CareFirst (Caremark)
Wounds associated with dystrophic epidermolysis bullosa (DEB)
Initial criteria
- Member is age ≥ 6 months
- Member has clinical manifestations of disease (e.g., extensive skin blistering, skin erosions, scarring)
- Member has laboratory test results confirming diagnosis (i.e., genetic testing, immunofluorescence mapping [IFM], transmission electron microscopy [TEM])
- Filsuvez will not be administered to wound(s) that are currently healed
- Medication must be prescribed by or in consultation with a dermatologist or wound care specialist
Reauthorization criteria
- All members (including new members) requesting continuation must meet all requirements in the coverage criteria section
Approval duration
12 months