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mechlorethamine gel — CareFirst (Caremark)

Smoldering adult T-cell leukemia/lymphoma (ATLL)

Initial criteria

  • Authorization may be granted for the treatment of smoldering adult T-cell leukemia/lymphoma (ATLL).

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