Becaplermin (Regranex gel 0.01 %®) Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

• Treatment of diabetic neuropathic ulcers which:
  • Are located at lower extremities
  • extends into the subcutaneous tissue or beyond

Exclusion Criteria

None

Required Medical Information

Show clinical evidence of adequate blood supply in the affected extremity, such as, presence of dorsalis pedis pulse, presence of postibial pulse, presence of popliteal pulse and no previous amputations due to gangrene

Age Restrictions

None

Prescriber Restrictions

None

Coverage Duration

Approved for up to 10 weeks initial therapy and 10 weeks for continuing therapy on renewal. Renewal as needed for 1 year.

Other Criteria

None