Vidaza — CareFirst (Caremark)

Initial criteria

• Authorization may be granted for the treatment of peripheral T-cell lymphoma (PTCL) including angioimmunoblastic T-cell lymphoma (AITL), nodal peripheral T-cell lymphoma with TFH phenotype (PTCL, TFH), or follicular T-cell lymphoma (FTCL) when all of the following are met: (1) The medication will be used as subsequent therapy for relapsed or refractory disease; AND (2) The medication will be used as a single agent.

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