COVERED USES:

FDA Approved Indications:

• Topical:
  • Primary cutaneous T-cell lymphoma, Stage 1A/1B with persistent/refractory disease after other topical therapies have failed or unable to tolerate other topical therapies.
• Oral:
  • Diagnosis of primary cutaneous T-cell lymphoma for all stages, refractory to one prior systemic therapy

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

Must be prescribed by an Oncologist.

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

Oral Targretin - primary T-cell Lymphoma refractory to at least one prior systemic therapy. Other systemic therapies may include, but not be limited to:

• Extracorporeal photopheresis, isotretinoin, interferon, vorinostat, denileukin diftitox, low-dose methotrexate

Topical Targretin Gel - primary cutaneous T-cell lymphoma, Stage 1A/1B with persistent/refractory disease after other topical therapies have failed or inability to tolerate other topical therapies. Other topical therapies may include, but not limited to:

• Corticosteroids, mechlorethamine hcl, carmustine, phototherapy (UVB or PUVA)

For all indications, documentation of response to Targretin must be submitted in order for continued authorization.

EXCLUSION CRITERIA:

Targretin® will not be approved for non-small cell lung cancer.

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.