Filsuvez — Medical Mutual

Initial criteria

• Patient is age ≥ 6 months
• Patient has at least one clinical feature of dystrophic epidermolysis bullosa [documentation required] AND patient has one or more open wound(s) that will be treated (target wound[s])
• Target wound(s) is clean in appearance and does not appear to be infected
• Target wound(s) is 10 cm2 to 50 cm2
• Target wound(s) is ≥ 21 days and < 9 months old
• Squamous cell and/or basal cell carcinoma has been ruled out for the target wound(s)
• Medication is prescribed by or in consultation with a dermatologist or wound care specialist

Reauthorization criteria

• Target wound(s) remains open according to the prescriber
• Target wound(s) has decreased in size from baseline according to the prescriber
• Medication is prescribed by or in consultation with a dermatologist or wound care specialist

Approval duration

3 months initial, 3 months reauth