Targretin gel — Cigna
cutaneous lesions of cutaneous T-cell lymphoma (Stage 1A and 1B)
Preferred products
- generic bexarotene gel
Initial criteria
- Patient meets the standard Oncology – Bexarotene (Topical) Prior Authorization Policy criteria; AND
- Patient has tried generic bexarotene gel [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 buffers, emollients, emulsifiers, preservatives, surfactants] 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