Regranex — CareFirst (Caremark)
Lower extremity diabetic neuropathic ulcer that extends into the subcutaneous tissue or beyond and has an adequate blood supply
Initial criteria
- Requested drug is being prescribed for the treatment of a lower extremity diabetic neuropathic ulcer that extends into the subcutaneous tissue or beyond AND has an adequate blood supply
- Good ulcer care practices including initial sharp debridement, pressure relief, and infection control will be performed
- If additional quantities are being requested, then the requested drug is being prescribed to treat an ulcer greater than 2.5 square inches in size OR multiple ulcers
Approval duration
20 weeks