Panretin gel (alitretinoin) — Highmark

Initial criteria

• age ≥ 18 years
• Prescribed by or in consultation with a dermatologist, oncologist, or infectious disease specialist
• Diagnosis of AIDS-related Kaposi’s sarcoma (ICD-10: C46.0)
• Used for the topical treatment of cutaneous lesions
• Member is not receiving systemic therapy for Kaposi sarcoma

Reauthorization criteria

• Prescriber attests that the member has experienced positive clinical response to therapy

Approval duration

12 months