Filsuvez (birch triterpenes topical gel) — Cigna

Initial criteria

• Patient is age ≥ 6 months; AND
• Patient has at least one clinical feature of dystrophic epidermolysis bullosa [documentation required] (examples include blistering, wounds, and scarring); AND
• Patient has one or more open wound(s) that will be treated (target wound[s]); AND
• According to the prescriber, target wound(s) meet ALL of the following: (1) Target wound(s) is clean and not infected; (2) Target wound(s) is 10 cm2 to 50 cm2; (3) Target wound(s) is ≥ 21 days and < 9 months old; (4) Squamous cell and/or basal cell carcinoma has been ruled out for the target wound(s); AND
• Medication is prescribed by or in consultation with a dermatologist or wound care specialist

Reauthorization criteria

• According to the prescriber, the target wound(s) remains open; AND
• According to the prescriber, the target wound(s) has decreased in size from baseline; AND
• Medication is prescribed by or in consultation with a dermatologist or wound care specialist

Approval duration

3 months