Targretin capsules (brand) — Cigna
cutaneous manifestations of cutaneous T-cell lymphoma in patients who are refractory to at least one prior systemic therapy
Preferred products
- generic bexarotene capsules
Initial criteria
- Patient meets the standard Oncology – Bexarotene (Oral) Prior Authorization Policy criteria; AND
- Patient has tried generic bexarotene capsules [documentation required]; AND
- Patient cannot continue to use the Preferred medication due to a formulation difference in the inactive ingredient(s) [e.g., difference in dyes, fillers, preservatives] between the brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Approval duration
1 year