Targretin (bexarotene) topical gel — Highmark

Preferred products

• generic topical bexarotene gel

Initial criteria

• age ≥ 18 years
• will be using Targretin gel for cutaneous lesions associated with Stage IA or Stage IB CTCL (ICD-10: C84.A)
• experienced therapeutic failure, contraindication, or intolerance to at least one other guideline-directed therapy: topical corticosteroids OR topical chemotherapy (e.g., carmustine) OR local radiation OR topical retinoid (e.g., tazarotene) OR phototherapy OR topical imiquimod OR topical mechlorethamine OR total skin electron beam radiation (TSEBT)
• if request is for brand Targretin topical gel, member has experienced therapeutic failure or intolerance to generic topical bexarotene gel

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 topical gel, prescriber provides documentation that the AB-rated generic is ineffective or not tolerated

Approval duration

12 months