azacitidine — United Healthcare

Initial criteria

• Diagnosis of one of the following T-cell lymphomas: Angioimmunoblastic T-cell lymphoma (AITL), Nodal peripheral T-cell lymphoma with TFH phenotype (PTCL, TFH), or Follicular T-cell lymphoma (FTCL)
• AND One of the following: Used as initial palliative intent therapy OR Used as second-line and subsequent therapy

Reauthorization criteria

• Patient does not show evidence of progressive disease while on Onureg therapy

Approval duration

12 months