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Valchlor — CareFirst (Caremark)

Lymphomatoid papulosis (LyP)

Initial criteria

  • Authorization may be granted for the treatment of lymphomatoid papulosis (LyP).

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