Targretin (bexarotene) oral capsules — Highmark

Preferred products

• generic oral bexarotene

Initial criteria

• age ≥ 18 years
• diagnosis of cutaneous manifestations of CTCL (ICD-10: C84.A)
• experienced therapeutic failure, contraindication, or intolerance to at least one guideline-directed systemic therapy: interferon-α-2b or interferon-γ-1b OR extracorporeal photochemotherapy OR systemic retinoids (e.g., acitretin, isotretinoin) OR methotrexate OR single agent or combination chemotherapies
• if request is for brand Targretin oral capsules, member has experienced therapeutic failure or intolerance to generic oral bexarotene

Reauthorization criteria

• prescriber attests that member is tolerating therapy and has experienced a therapeutic response defined as disease improvement OR delayed disease progression
• if request is for brand Targretin oral capsules, prescriber provides documentation that the AB-rated generic is ineffective or not tolerated

Approval duration

12 months