Bexarotene Gel Prior Authorization Criteria - Medicare Part D

PA applies to new starts only Initial Evaluation  Bexarotene 1% gel will be approved when BOTH of the following are met:   

1. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication AND
2. ONE of the following:
   1. There is evidence of a claim that the patient has been treated with the requested medication within the past 180 days
      OR
   2. The prescriber states the patient is currently being treated with the requested medication
      OR
   3. ALL of the following: 
      1. ONE of the following: 
         1. BOTH of the following:
            1. The patient has a diagnosis of stage IA or IB cutaneous T-cell lymphoma (CTCL) with cutaneous lesions
               AND
            2. ONE of the following:
               1. The patient has refractory or persistent disease despite a previous treatment trial with a skin-directed therapy (e.g., topical corticosteroid, topical imiquimod)
                  OR
               2. The patient has an intolerance or hypersensitivity to a previous treatment trial with a skin-directed therapy (e.g., topical corticosteroid, topical imiquimod)
                  OR
               3. The patient has an FDA labeled contraindication to a previous treatment trial with a skin-directed therapy (e.g., topical corticosteroid, topical imiquimod)
                  OR
         2. The patient has an indication that is supported in CMS approved compendia for the requested medication
            AND
      2. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, oncologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
         AND
      3. The patient does NOT have any FDA labeled contraindications to the requested medication

Length of Approval: 12 months

Renewal Evaluation

Bexarotene 1% gel will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND
2. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication 
   AND
3. ONE of the following:
   1. There is evidence of a claim that the patient is currently being treated with the requested medication within the past 180 days
      OR
   2. The prescriber states the patient is currently being treated with the requested medication
      OR
   3. ALL of the following: 
      1. The patient has had clinical benefit with the requested medication
         AND
      2. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, oncologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
         AND
      3. The patient does NOT have any FDA labeled contraindications to the requested medication

Length of Approval: 12 months