thalidomide — CareFirst (Caremark)
Rosai-Dorfman disease
Initial criteria
- Authorization of 12 months may be granted for treatment of multiple myeloma.
- Authorization of 12 months may be granted for treatment and prevention of erythema nodosum leprosum.
- Authorization of 12 months may be granted for treatment of Crohn’s disease.
- Authorization of 12 months may be granted for treatment of Kaposi sarcoma as subsequent therapy.
- Authorization of 12 months may be granted for treatment of chronic graft-versus-host disease.
- Authorization of 12 months may be granted for treatment of multicentric Castleman disease.
- Authorization of 12 months may be granted for treatment of AIDS-related aphthous stomatitis and recurrent aphthous stomatitis in immunocompromised members.
- Authorization of 12 months may be granted for treatment of histiocytic neoplasms, including Langerhans cell histiocytosis and Rosai-Dorfman disease, as a single agent.
- Authorization of 12 months may be granted for treatment of recurrent or progressive pediatric medulloblastoma as part of MEMMAT regimen.
Reauthorization criteria
- Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for multiple myeloma, multicentric Castleman disease, histiocytic neoplasms, Kaposi sarcoma, or pediatric medulloblastoma when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
- Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for other covered indications who have improvement in symptoms and no unacceptable toxicity.
Approval duration
12 months