COVERED USES:

FDA Approved Indications:

• Primary cutaneous T-cell lymphoma, all stages, refractory to one prior systemic therapy;
• Primary cutaneous T-cell lymphoma, Stage 1A/1B, persistent/refractory after other therapies or unable to tolerate other therapies.

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:

Targretin® is approved for the following FDA approved indication:

• Treatment of cutaneous manifestations of cutaneous T-cell lymphoma in patients who are refractory to at least one prior systemic therapy regimens. (202.1_, 202.2_, 202.8_)
• Starting dose should not exceed 300mg/ m2/ day.
• 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.