Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Pralatrexate (Folotyn) may be considered medically necessary for ANY of the following indications:
- For the treatment of relapsed or refractory peripheral T-cell lymphoma (PTCL); or
Compendia Sources
Pralatrexate (Folotyn) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of pralatrexate (Folotyn) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
