Pharmacy Prior Authorization Criteria

Targretin (bexarotene)

Indications for Prior Authorization

Targretin (bexarotene) capsules

• For diagnosis of Cutaneous T-Cell Lymphoma
  Indicated for the treatment of cutaneous manifestations of cutaneous T-cell lymphoma in patients who are refractory to at least one prior systemic therapy.

Targretin (bexarotene) gel 1%

• For diagnosis of Cutaneous T-Cell Lymphoma
  Indicated for the topical treatment of cutaneous lesions in patients with cutaneous T-cell lymphoma (Stage 1A and 1B) who have refractory or persistent disease after other therapies or who have not tolerated other therapies.

Criteria

Brand Targretin capsules, Generic bexarotene capsules, Brand Targretin gel, Generic bexarotene Gel

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of cutaneous T-cell lymphoma (CTCL) [A]
AND
• Trial and failure, contraindication, or intolerance to at least one prior therapy (including skin-directed therapies [e.g., corticosteroids {i.e., clobetasol, diflorasone, halobetasol, augmented betamethasone dipropionate}, topical mechlorethamine, phototherapy] or systemic therapies [e.g., brentuximab vedotin, methotrexate])
AND
• Trial and failure, contraindication, or intolerance to generic Targretin (Applies to brand Targretin only)

Brand Targretin capsules, Generic bexarotene capsules, Brand Targretin gel, Generic bexarotene Gel

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of disease progression while on therapy

P & T Revisions

2024-08-01, 2023-08-08, 2022-07-26, 2022-07-08, 2021-07-28, 2021-05-26, 2021-05-25, 2020-07-27, 2019-10-28, 2019-07-29

References

1. Targretin prescribing information. Bausch Health US, LLC. Bridgewater, NJ. April 2020.
2. Targretin gel 1% prescribing information. Bausch Health US, LLC. Bridgewater, NJ. February 2020.
3. National Comprehensive Cancer Network (NCCN). Primary Cutaneous Lymphomas v.2.2024. Available at: https://www.nccn.org/professionals/physician_gls/pdf/primary_cutaneous.pdf Accessed on July 18, 2024.

---

Revision History

• 2024-08-01: 2024 Annual Review. No change to clinical intent. Updated drug example
• 2023-08-08: Annual Review
• 2022-07-26: Annual Review
• 2022-07-08: Update guideline
• 2021-07-28: Annual Review
• 2021-05-26: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
• 2020-07-27: Annual Review: no criteria changes, updated references and background
• 2019-10-28: Updated to specialty product for 01/01/2020. Added embedded step through generic for brand Targretin capsules. SL 10.28.19
• 2019-07-29: 2019 Annual Review

---