Denileukin diftitox Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

Treatment of persistent or recurrent cutaneous T-cell lymphoma when malignant cells express the CD25 component of the interleukin-2 receptor

Exclusion Criteria

None

Required Medical Information

None

Age Restrictions

None

Prescriber Restrictions

None

Coverage Duration

Every prescription is authorized for up to six (6) months depending on refills written in prescription

Other Criteria

None