Pharmacy Prior Authorization Criteria

Valchlor (mechlorethamine gel)

Indications for Prior Authorization

Valchlor (mechlorethamine gel)

• For diagnosis of Mycosis fungoides-type cutaneous T-cell lymphoma (MF-CTCL)
  Indicated for the topical treatment of Stage IA and IB mycosis fungoides-type cutaneous T-cell lymphoma in patients who have received prior skin-directed therapy.

Criteria

Valchlor

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• One of the following diagnoses:
• Stage IA mycosis fungoides-type cutaneous T-cell lymphoma (MF-CTCL)
• Stage IB mycosis fungoides-type cutaneous T-cell lymphoma (MF-CTCL)
AND
• Patient has received at least one prior skin-directed therapy (e.g., topical corticosteroids [e.g., clobetasol, fluocinonide], phototherapy, bexarotene topical gel [Targretin topical gel], etc.)

Valchlor

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2024-06-05, 2023-06-19, 2022-06-02, 2021-06-08, 2020-04-28

References

1. Valchlor Prescribing Information. Helsinn Therapeutics (U.S.), Inc. Iselin, NJ. January 2020.

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Revision History

• 2024-06-05: 2024 Annual Review. Removed specialist requirement.
• 2023-06-19: Annual Review
• 2022-06-02: Annual review: Updated criteria and background.
• 2021-06-08: 2021 Annual Review
• 2020-04-28: Annual Review: updated references

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