Filsuvez (birch triterpenes) — Highmark

Initial criteria

• age ≥ 6 months
• member has a diagnosis of dystrophic epidermolysis bullosa (DEB) (ICD-10: Q81.2) OR member has a diagnosis of junctional epidermolysis bullosa (JEB) (no ICD-10 code)
• member has one or more open wounds

Reauthorization criteria

• prescriber attests that the target wound responded positively to therapy
• prescriber attests that the member requires additional courses of treatment

Approval duration

initial: up to 3 months; reauthorization: up to 12 months