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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsHawaii HMSA Valchlor Prior Auth Coverage | OpenPay…
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    CurrentHawaii Medical Service Association (HMSA)Policy 1862-A

    Valchlor (mechlorethamine gel) Coverage Criteria

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    This policy governs HMSA coverage and prior authorization for Valchlor topical gel for specified cutaneous lymphomas and histiocytic neoplasms when applicable approval criteria are met and no exclusions apply.

    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicyValchlor (mechlorethamine gel) Coverage Criteria
    Policy CodePolicy 1862-A
    Change TypeNo material change
    Effective DateJul 1, 2023
    Next Review DateNot specified
    Key ActionObtain prior authorization for Valchlor and document a covered indication with all applicable approval criteria met.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsAuthorization period
    IA or IB

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    FDA-approved disease stages
    5Compendial-use categories
    No progression or toxicityContinuation requirement

    Covered Indications

    FDA-approved indication

    Covered for the FDA-approved indication when all of the following are met.

    FDA-approved indication: Patient has Stage IA or IB mycosis fungoides-type cutaneous T-cell lymphoma and has received prior skin-directed therapy.Stage IA or IB; prior skin-directed therapy

    Mycosis fungoides/Sezary syndrome

    Covered when the member is being treated for the listed indication.

    Mycosis fungoides or Sezary syndrome: Member has mycosis fungoides or Sezary syndrome.

    Initial authorization may be granted for 12 months.

    Adult T-cell leukemia/lymphoma

    Covered when the member is being treated for the listed indication.

    Adult T-cell leukemia/lymphoma: Member has chronic or smoldering adult T-cell leukemia/lymphoma.Chronic or smoldering disease

    Initial authorization may be granted for 12 months.

    Primary cutaneous B-cell lymphoma

    Covered when the member is being treated for the listed indication.

    Primary cutaneous B-cell lymphoma: Member has primary cutaneous marginal zone lymphoma or primary cutaneous follicle center lymphoma.

    Initial authorization may be granted for 12 months.

    Lymphomatoid papulosis

    Covered when the member is being treated for the listed indication.

    Lymphomatoid papulosis: Member has lymphomatoid papulosis.

    Initial authorization may be granted for 12 months.

    Histiocytic neoplasms

    Covered when the member is being treated for the listed indication.

    Histiocytic neoplasm: Member has Langerhans cell histiocytosis with isolated skin disease.Isolated skin disease

    Initial authorization may be granted for 12 months.

    Continuation therapy

    Covered for continuation therapy when all of the following are met.

    Continuation therapy: Member is requesting reauthorization for an indication listed in the initial approval criteria and has no evidence of unacceptable toxicity or disease progression while on the current regimen.No unacceptable toxicity or disease progression

    Continuation authorization may be granted for 12 months.

    Authorization and Coverage Requirements

    Prior Authorization

    Initial and Continuation Authorization

    Prior authorization is required. Authorization may be granted for 12 months for eligible initial treatment and for continuation of therapy when the applicable criteria are met.

    • Initial authorization: 12 months may be granted for treatment of mycosis fungoides or Sezary syndrome.
    • Continuation authorization: 12 months may be granted for reauthorization of an indication listed in the initial-approval criteria.
    Denial Risk

    Approval Criteria and Exclusions

    Coverage is available only when all applicable approval criteria are met and the member has no exclusions to the prescribed therapy.

    • Apply the applicable approval criteria for the requested indication.
    • Confirm that no exclusions apply to the prescribed therapy.

    Therapy Overview

    Valchlor (mechlorethamine gel) is a topical therapy used for selected cutaneous lymphomas and related skin-limited neoplasms. HMSA considers the FDA-approved indication and specified compendial uses covered when applicable approval criteria are met and the member has no exclusions to the prescribed therapy.

    The FDA-approved use is topical treatment of Stage IA or IB mycosis fungoides-type cutaneous T-cell lymphoma in patients who have received prior skin-directed therapy. The policy also addresses specified uses in mycosis fungoides or Sezary syndrome, adult T-cell leukemia/lymphoma, primary cutaneous B-cell lymphoma, lymphomatoid papulosis, and Langerhans cell histiocytosis with isolated skin disease.

    Initial Authorization Criteria

    FDA-approved indication

    The FDA-approved indication is covered when the following criteria are met.

    FDA-approved indication: Patient has Stage IA or IB mycosis fungoides-type cutaneous T-cell lymphoma and has received prior skin-directed therapy.Stage IA or IB; prior skin-directed therapy

    Compendial uses

    Authorization of 12 months may be granted for treatment of the following indications.

    • Mycosis fungoides or Sezary syndrome: Member has mycosis fungoides or Sezary syndrome.
    • Adult T-cell leukemia/lymphoma:

    Continued Treatment Authorization

    Continuation therapy

    Authorization of 12 months may be granted for continued treatment when all of the following are met.

    Continuation therapy: The request is for reauthorization for an indication listed in the initial approval criteria, with no evidence of unacceptable toxicity or disease progression while on the current regimen.No unacceptable toxicity or disease progression
    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicyValchlor (mechlorethamine gel) Coverage Criteria
    Policy CodePolicy 1862-A
    Change TypeNo material change
    Effective DateJul 1, 2023
    Next Review DateNot specified
    Key ActionObtain prior authorization for Valchlor and document a covered indication with all applicable approval criteria met.
    SourceLink
    On This Page
    Covered IndicationsAuthorization and Coverage RequirementsTherapy OverviewInitial Authorization CriteriaContinued Treatment Authorization
    Denial Risk

    Continuation: Toxicity or Disease Progression

    Continuation authorization may be granted only when there is no evidence of unacceptable toxicity or disease progression while the member is on the current regimen.

    • For reauthorization, document absence of unacceptable toxicity.
    • For reauthorization, document absence of disease progression.
    Member has chronic or smoldering adult T-cell leukemia/lymphoma.
    Chronic or smoldering disease
  1. Primary cutaneous B-cell lymphoma: Member has primary cutaneous marginal zone lymphoma or primary cutaneous follicle center lymphoma.
  2. Lymphomatoid papulosis: Member has lymphomatoid papulosis.
  3. Histiocytic neoplasm: Member has Langerhans cell histiocytosis with isolated skin disease.Isolated skin disease