Pharmacy Prior Authorization Criteria

Zolinza (vorinostat)

For diagnosis of Cutaneous T-cell Lymphoma
Indicated for treatment of cutaneous manifestations in patients with cutaneous T-cell lymphoma (CTCL) who have progressive, persistent or recurrent disease on or following two systemic therapies.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

AND

Patient has progressive, persistent or recurrent disease on or following two systemic therapies (e.g., extracorporeal photopheresis [ECP], systemic retinoids, interferons) [A]

History of contraindication or intolerance to other systemic therapies (e.g., Adcetris [brentuximab vedotin, Cytoxan [cyclophosphamide], Poteligeo [mogamulizumab]) [A]

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

2024-09-04, 2023-08-23, 2023-07-05, 2022-08-14, 2021-09-09, 2021-05-26, 2021-05-25, 2020-09-10, 2019-09-18

Zolinza Prescribing Information. Merck & Co, Inc. Whitehouse Station, NJ. July 2022
National comprehensive cancer network (NCCN) clinical practice guidelines in oncology: Primary cutaneous lymphomas. v.2.2024. Available at: https://www.nccn.org/professionals/physician_gls/pdf/primary_cutaneous.pdf. Accessed August 6, 2024.

Examples of systemic therapies include (but are not limited to): [2] Adcetris (brentuximab vedotin), Cytoxan (cyclophosphamide), Doxil (pegylated doxorubicin), Extracorporeal photochemotherapy, Folotyn (pralatrexate), Gemzar (gemcitabine), Interferon-alpha, Leukeran (chlorambucil), Nipent (pentostatin), Poteligeo (mogamulizumab), Targretin (bexarotene), Temodar (temozolamide), Toposar (etoposide), Trexall (methotrexate), Velcade (bortezomib)

2024-09-04: 2024 Annual Review. No change to clinical intent. Formatting updates to criteria. Background updates
2023-08-23: 2023 Annual Review
2023-07-05: guideline update
2022-08-14: 2022 Annual Review
2021-09-09: 2021 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
2020-09-10: 2020 Annual Review: updated reauthorization criteria and references
2019-09-18: 2019 Annual Review. No clinical criteria changes.