CurrentCignaPolicy N/A

Oncology - Bexarotene (Oral) Preferred Specialty Management Policy

Defines Cigna's preferred product program and prior authorization/exception criteria for oral bexarotene (brand Targretin and generic capsules) for treatment of cutaneous T-cell lymphoma and related cutaneous lymphomas; applies to health benefit plans administered by Cigna companies.

Policy Summary

PayerCigna

PolicyOncology - Bexarotene (Oral) Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 15, 2023

Next Review DateFeb 12, 2025

Key ActionObtain prior authorization and document trial of generic bexarotene (or justification for brand Targretin exception) for approvals up to 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearapproval duration

Preferred then non-preferredstep therapy

requireddocumentation

NCCN v1.2025guideline

Coverage Criteria for Oral Bexarotene

Policy Summary

PayerCigna

PolicyOncology - Bexarotene (Oral) Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 15, 2023

Next Review DateFeb 12, 2025

Key ActionObtain prior authorization and document trial of generic bexarotene (or justification for brand Targretin exception) for approvals up to 1 year.

SourceLink

On This Page

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Non-preferred product exception (brand Targretin): A) Patient meets the standard Oncology - Bexarotene (Oral) Prior Authorization Policy criteria; AND B) Patient has tried generic bexarotene capsules (documentation required); AND C) Patient cannot continue to use the Preferred medication due to a formulation difference in the inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) between the brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction (documentation required)

Approval duration: 1 year

Provider Actions and Requirements

Prior Authorization

Prior authorization required

Prior authorization is required per the standard Oncology - Bexarotene (Oral) Prior Authorization Policy. All approvals are provided for 1 year in duration.

Step Therapy

Preferred product trial required

The program requires the patient to try a Preferred Product (generic bexarotene capsules) before approval of the Non-Preferred Product (brand Targretin); if PA criteria are met but the preferred product has not been tried, approval will be for the Preferred Product.

Documentation Required

Documentation requirements

Documentation is required where noted in the criteria and may include chart notes, prescription claims records, and prescription receipts; documentation is specifically required to show trial of generic bexarotene and to support formulation-related allergy or serious adverse reaction for a brand exception.

Denial Risk

Non-preferred product exception required or request denied

Requests for non-preferred bexarotene (brand Targretin) will be denied unless the patient meets the Non-Preferred Product Exception Criteria, which require meeting the standard PA criteria, trial of generic bexarotene, and documented formulation-related intolerance or significant allergy/serious adverse reaction.

Exception criteria require all of: A) standard Oncology - Bexarotene (Oral) PA criteria; B) trial of generic bexarotene capsules [documentation required]; C) inability to use the Preferred product due to inactive-ingredient formulation differences causing significant allergy or serious adverse reaction [documentation required].
Any other exception to allow the Non-Preferred Product is considered not medically necessary.

Covered Products and Regimens

Product	Coverage status	Coverage detail / conditions
generic bexarotene capsules
Preferred product for indicated cutaneous lymphomas when prior authorization criteria are met; approve per the standard Oncology - Bexarotene (Oral) Prior Authorization Policy (approvals provided for 1 year).
Preferred product; trial required before coverage of non-preferred (brand) unless non-preferred exception criteria are met. Documentation of trial may be required.

Product	Coverage status	Coverage detail / conditions
Targretin capsules (brand)
Covered only if non-preferred product exception criteria are met; approve for 1 year when ALL criteria A, B, and C are satisfied.
Exception criteria: A) patient meets the standard Oncology - Bexarotene (Oral) Prior Authorization Policy criteria; AND B) patient has tried generic bexarotene capsules (documentation required); AND C) patient cannot continue the Preferred medication due to formulation differences in inactive ingredients that per the prescriber would cause a significant allergy or serious adverse reaction (documentation required). Any other exception is considered not medically necessary.

Definitions

Oral bexarotene (bexarotene capsules, Targretin) — Indication

IndicationTreatment of cutaneous manifestations of cutaneous T‑cell lymphoma in patients refractory to at least one prior systemic therapy.

NCCN guidanceNCCN Primary Cutaneous Lymphomas (v1.2025) lists oral bexarotene as an option for cutaneous lymphomas (mycosis fungoides, Sézary syndrome, ALCL, lymphomatoid papulosis) for initial and relapsed/refractory therapy.

Examples of covered cancer typesMycosis fungoides; Sézary syndrome; anaplastic large cell lymphoma (ALCL); lymphomatoid papulosis.

Prerequisite therapy contextIndicated for patients refractory to at least one prior systemic therapy (per prescribing information).

Background

Oral bexarotene (bexarotene capsules) is managed under a Preferred Specialty Management program that designates generic bexarotene capsules as the Preferred Product and Targretin (brand) as Non-Preferred. Brand Targretin may be approved for 1 year only when all of the following are met: A) the patient meets the standard Oncology - Bexarotene (Oral) prior authorization criteria; B) the patient has tried generic bexarotene capsules (documentation required); and C) the prescriber documents that the patient cannot continue the Preferred Product because of a formulation difference in inactive ingredients that would cause a significant allergy or serious adverse reaction (documentation required). If the prior authorization criteria are met but the exception criteria B and/or C are not met, approve the Preferred Product (generic bexarotene capsules) instead.

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