mechlorethamine gel — CareFirst (Caremark)
Langerhans cell histiocytosis with isolated skin disease
Initial criteria
- Authorization may be granted for the treatment of Langerhans cell histiocytosis with isolated skin disease.
Reauthorization criteria
- Authorization may be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
Approval duration
12 months