Valchlor (mechlorethamine) — United Healthcare

Initial criteria

• Diagnosis of one of the following:
• Chronic or smoldering T-cell leukemia/lymphoma OR Primary cutaneous marginal zone or follicle center B-cell lymphoma OR Lymphomatoid papulosis (LyP) with extensive lesions OR Mycosis fungoides (MF)/Sezary syndrome (SS)

Reauthorization criteria

• Patient does not show evidence of progressive disease while on Valchlor

Approval duration

12 months