Subject: Vandetanib (Caprelsa ) Tablets
|
|
- Debra Gray
- 5 years ago
- Views:
Transcription
1 09-J Original Effective Date: 10/15/11 Reviewed: 11/14/18 Revised: 12/15/18 Subject: Vandetanib (Caprelsa ) Tablets THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION. Position Statement Dosage/Administratio n Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines Other References Updates DESCRIPTION: The main histologic types of thyroid cancer include differentiated (papillary, follicular, and Hurthle cell), medullary, and anaplastic. Medullary thyroid carcinoma (MTC) is a malignancy of the parafollicular C cells of the thyroid gland. Neither radiotherapy nor chemotherapy has demonstrated durable objective responses in persons with advanced MTC. Evidence from preclinical studies of molecular targeted therapeutics with activity against rearranged during transfection (RET) proto-oncogene demonstrate that RET kinase is a potential therapeutic target in MTC. Other signaling pathways likely to contribute to the growth and invasiveness of MTC include vascular endothelial growth factor receptor (VEGFR)-dependent tumor angiogenesis and epidermal growth factor receptor (EGFR)-dependent tumor cell proliferation. Vandetanib (Caprelsa ) is a novel small-molecule kinase inhibitor. In vitro studies have shown that vandetanib inhibits the activity of multiple tyrosine kinases, including members of the epidermal growth factor receptor (EGFR) family, vascular endothelial growth factor (VEGF) receptors, RET, protein tyrosine kinase 6, TIE2, members of the EPH receptors kinase family, and members of the Src family of tyrosine kinases. Vandetanib inhibits endothelial cell migration, proliferation, and survival and new blood vessel formation in in vitro models of angiogenesis. Vandetanib inhibits EGFR-dependent cell survival in vitro. In addition, vandetanib inhibits epidermal growth factor stimulated receptor tyrosine kinase phosphorylation in tumor cells and endothelial cells and VEGF-stimulated tyrosine kinase phosphorylation in endothelial cells. Vandetanib was evaluated in a double-blind, randomized trial of 331 patients with unresectable, locally advanced or metastatic MTC. In comparison to placebo, vandetanib increased progression free survival (hazard ratio 0.35, 95% CI ). The FDA approved vandetanib for the treatment of symptomatic or progressive MTC in patients with unresectable locally advanced or metastatic disease through a restricted access program due to the potential for cardiac toxicity.
2 National Comprehensive Cancer Network (NCCN) Guidelines for Thyroid cancer currently recommend vandetanib for both MTC and differentiated thyroid cancers (papillary, follicular, and Hurthle cell). Of note, NCCN states that several factors should be considered prior to initiating therapy with a kinase inhibitor which includes the following: therapy may improve progression-free survival but is not curative, side effects may have a significant effect on quality of life, rates of disease progression are variable, and the pace of disease progression should be factored into treatment decisions. More specifically, patients with indolent disease who are asymptomatic may not be appropriate for kinase inhibitors due to side effects adversely affecting the patient s quality of life whereas patients with rapidly progressing disease may experience benefit even in the presence of side effects. Vandetanib is also recommended by NCCN for the treatment of non-small cell lung cancer when positive for RET gene rearrangements. POSITION STATEMENT: Comparative Effectiveness The Food and Drug Administration has deemed the drug(s) or biological product(s) in this coverage policy to be appropriate for self-administration or administration by a caregiver (i.e., not a healthcare professional). Therefore, coverage (i.e., administration) in a provider-administered setting such as an outpatient hospital, ambulatory surgical suite, physician office, or emergency facility is not considered medically necessary. I. Initiation of vandetanib (Caprelsa ) meets the definition of medical necessity when administered for the indications listed in Table 1 and ALL of the indication-specific criteria are met: Table 1 Indications Specific Criteria Non-small cell lung cancer ALL of the following are met: 1. Member has tested positive for RET gene rearrangements 2. Vandetanib is used as a single agent 3. Dose does not exceed 300 mg/day using the fewest number of tablets per day Medullary thyroid carcinoma ALL of the following are met: 1. Member s disease is progressive and/or symptomatic 2. Member has ONE of the following: a. Unresectable locoregional disease b. Distant metastatic disease 3. Vandetanib is used as a single agent 4. Dose does not exceed 300 mg/day using the fewest number of tablets per day
3 Follicular carcinoma Hurthle cell carcinoma Papillary carcinoma ALL of the following are met: 1. Member s disease is progressive and/or symptomatic 2. Member has ONE of the following: a. Unresectable locoregional disease that is recurrent or persistent b. Distant metastatic disease 3. Member s disease is resistant to radioiodine treatment 4. Vandetanib is used as a single agent 5. Dose does not exceed 300 mg/day using the fewest number of tablets per day Approval duration: 180 days II. Vandetanib (Caprelsa ) meets the definition of medical necessity when used as a single agent for the following designated Orphan Drug indication ( when the dose does not exceed the maximum FDA-approved dosing: a. Anaplastic thyroid cancer Approval duration: 1 year III. Continuation of vandetanib (Caprelsa ) meets the definition of medical necessity for the indications in Table I and orphan indications when ALL of the following criteria are met: A. The member s disease has not progressed while receiving treatment with vandetanib B. The member has been previously approved by Florida Blue or another health plan in the past 2 years, OR the member has previously met all indication-specific criteria for coverage C. The dose does not exceed 300 mg per day and will be achieved using the fewest number of tablets per day. Approval duration: 1 year DOSAGE/ADMINISTRATION: THIS INFORMATION IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND SHOULD NOT BE USED AS A SOURCE FOR MAKING PRESCRIBING OR OTHER MEDICAL DETERMINATIONS. PROVIDERS SHOULD REFER TO THE MANUFACTURER S FULL PRESCRIBING INFORMATION FOR DOSAGE GUIDELINES AND OTHER INFORMATION RELATED TO THIS MEDICATION BEFORE MAKING ANY CLINICAL DECISIONS REGARDING ITS USAGE. FDA-Approved: Vandetanib is approved for the treatment of adult members with symptomatic or progressive medullary thyroid carcinoma with unresectable locally advanced or metastatic disease. The use of vandetanib in the treatment of indolent, asymptomatic or slowly progressing disease should be carefully considered because of the treatment related risk of vandetanib.
4 Vandetanib 300 mg should be taken once daily, with or without food. Vandetanib tablets should be swallowed intact and should not be crushed. Vandetanib therapy should be continued until members are no longer benefiting from treatment or an unacceptable toxicity occurs. Recommended Dose Adjustments: Corrected QT interval (corrected for heart rate using Fridericia s formula [QTcF]) exceeds 500 ms: interrupt dosing until toxicity returns to less than 450 ms, then resume at a reduced dose Common Terminology Criteria for Adverse Events (CTCAE) grade 3 or greater toxicity: interrupt dosing until toxicity resolves to CTCAE grade 1, and then resume at a reduced dose. The 300 mg daily dose can be reduced to 200 mg (two 100 mg tablets) and then to 100 mg for CTCAE grade 3 or greater toxicities. Note: Because of the 19-day half-life, adverse reactions, including a prolonged QT interval, may not resolve quickly. Monitor appropriately. Moderate (creatinine clearance [CrCl] ml/min) and severe renal impairment (CrCl < 30 ml/min): reduce the starting dose to 200 mg (two 100 mg tablets) daily. Hepatic Impairment: vandetanib was not studied in members with moderate (Child-Pugh class B) and severe (Child-Pugh class C) hepatic insufficiency and should be avoided in this member population. Missed Dose: If a member misses a dose, the missed dose should not be taken if it is less than 12 hours before the next dose. Drug Availability: Vandetanib is available as 100- and 300 mg film-coated tablets. Vandetanib is not available at retail pharmacies and can only be dispensed through a restricted distribution program. CONTRAINDICATIONS Vandetanib is contraindicated in members with congenital long QT syndrome. PRECAUTIONS/ WARNINGS: Boxed Warning Vandetanib can prolong the QT interval. Torsades de pointes and sudden death have occurred. Use should be avoided in persons with hypocalcemia, hypokalemia, hypomagnesemia, or long QT syndrome. Avoid use in combination with agents known to prolong the QT interval. Warnings Prolonged QT Interval, Torsades de pointes, ventricular tachycardia and sudden death: Monitor electrocardiograms and levels of serum potassium, calcium, magnesium and TSH. Reduce vandetanib dose as appropriate. Do not initiate treatment if the QTcF interval is greater than 450 ms. Severe skin reactions, including Stevens-Johnson syndrome, some resulting in death: Consider discontinuation of vandetanib for severe skin reactions. Photosensitivity can occur up during treatment and up to 4 months after treatment discontinuation. Interstitial lung disease (ILD) or pneumonitis, including fatalities: investigate unexplained nonspecific respiratory signs and symptoms. Discontinue vandetanib for confirmed ILD. Ischemic cerebrovascular events, hemorrhage, heart failure, diarrhea, hypertension, and reversible posterior leukoencephalopathy syndrome: Discontinue or interrupt vandetanib.
5 Hypothyroidism may occur: monitor TSH during treatment. Embryo-fetal toxicity: Can cause fetal harm. Advise women of the potential risk to a fetus and to avoid pregnancy during and for four months following treatment with vandetanib. Vandetanib Risk Evaluation and Mitigation Strategy (REMS) Program: A REMS is required for vandetanib due to the risk of QT prolongation, Torsades de pointes, and sudden death. Vandetanib is available only through the restricted distribution program called CAPRELSA REMS Program. The program requires prescribers and pharmacies to be certified to prescribed and dispense vandetanib. For more information about the specific REMS requirements or to enroll in the CAPRELSA REMS program, visit or call BILLING/CODING INFORMATION: HCPCS Coding: C9399 Unclassified drugs or biologicals. J8999 Prescription drug, oral, chemotherapeutic, NOS ICD-10 Diagnosis Codes That Support Medical Necessity: C33 Malignant neoplasm of trachea C34.00 C34.02 Malignant neoplasm of unspecified main bronchus C34.10 C34.12 Malignant neoplasm of upper lobe, unspecified bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung C34.30 C34.32 Malignant neoplasm of lower lobe, unspecified bronchus or lung C34.80 C34.82 Malignant neoplasm of overlapping sites of unspecified bronchus and lung C34.90 C34.92 Malignant neoplasm of unspecified part of unspecified bronchus or lung C73 Malignant neoplasm of thyroid gland REIMBURSEMENT INFORMATION: Refer to section entitled POSITION STATEMENT. PROGRAM EXCEPTIONS: Federal Employee Program (FEP): Follow FEP guidelines.
6 State Account Organization (SAO): Follow SAO guidelines. Medicare Advantage products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline revised date. Medicare Part D: Florida Blue has delegated to Prime Therapeutics authority to make coverage determinations for the Medicare Part D services referenced in this guideline. DEFINITIONS: Medullary thyroid carcinoma (MTC): A form of thyroid carcinoma which originates from the parafollicular cells (C cells), which produce the hormone calcitonin. RELATED GUIDELINES: Cabozantinib (Cometriq ), 09-J OTHER: Table 1: Common Terminology Criteria for Adverse Events v4.0 (CTCAE) Grade Description 1 Mild; asymptomatic or mild symptoms; clinical diagnostic observations only; intervention not indicated 2 Moderate; minimal, local or noninvasive intervention indicated; limited age-appropriate instrumental activities of daily living 3 Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care activities of daily living 4 Life-threatening consequences; urgent intervention indicated 5 Death related to adverse event REFERENCES: 1. AHFS Drug Information. Bethesda (MD): American Society of Health-System Pharmacists, Inc; 2016 [cited 2016 Aug 25]. In: STAT!Ref Online Electronic Medical Library [Internet]. Available from: 2. American Cancer Society: Cancer Facts and Figures Available at Accessed Sept 24, Caprelsa (vandetanib) [package insert]. AstraZeneca Pharmaceuticals LP. Wilmington (DE): July 2016.
7 4. Clinical Pharmacology. [database online]. Tampa, FL: Gold Standard, Inc.; URL: Accessed 10/29/ Food and Drug Administration. Center for Drug Evaluation and Research: Application number : Summary review. Accessed 08/09/ Micromedex Healthcare Series [Internet database]. Greenwood Village, Colorado: Thomson Healthcare. Updated periodically. Accessed 10/29/ Ingenix HCPCS Level II, Expert Ingenix ICD-9-CM for Physicians-Volumes 1 & 2, Expert Kloos RT, Eng C, Evans DB, et al. Medullary thyroid cancer: management guidelines of the American Thyroid Association. Thyroid 2009;19(6): National Cancer Institute. Common Terminology Criteria for Adverse Events. Available at: Accessed 9/24/ National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version Non-small cell lung cancer. Available at Accessed 10/29/ National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Version Thyroid Carcinoma. Available at Accessed 10/29/ National Comprehensive Cancer Network (NCCN). Drugs & Biologics Compendium [Internet]. Fort Washington (PA): National Comprehensive Cancer Network; 2018 [cited 2018 Oct 29]. Available from: Orphan Drug Designations and Approval [Internet]. Silver Spring (MD): US Food and Drug Administration; 2018 [cited 2018 Oct 29]. Available from: Wells SA, Robinson BG, Gagel RF. Vandetanib in members with locally advanced or metastatic medullary thyroid cancer: a randomized, double-blind, Phase III trial. J Clin Oncol. 2012; 30: Wells SA, Sylvia LA, Henning D et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid. 2015; 25: COMMITTEE APPROVAL: This Medical Coverage Guideline (MCG) was approved by the Florida Blue Pharmacy Policy Committee on 11/14/18. GUIDELINE UPDATE INFORMATION: 10/15/11 New Medical Coverage Guideline. 10/15/12 Review and revision to guideline; consisting of revising position statement, dosage and administration, and precautions sections; updating reference section; and adding contraindication. 11/15/13 Review and revision to guideline; consisting of updating references and program exceptions.
8 11/15/14 Review and revision to guideline; consisting of revising position statement and precautions section; updating references. 11/01/15 Revision: ICD-9 Codes deleted. 11/15/15 Review and revision to guideline; consisting of revising position statement, dosing/administration, warnings/precautions, coding and references. 10/15/16 Review and revision to guideline; consisting of revising position statement, description and references. 12/15/17 Review and revision to guideline; consisting of revising position statement, description, coding and references. 12/15/18 Review and revision to guideline; consisting of updating references.
Subject: Axitinib (Inlyta ) Tablets
09-J1000-67 Original Effective Date: 05/15/12 Reviewed: 12/12/18 Revised: 01/15/19 Subject: Axitinib (Inlyta ) Tablets THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationSubject: Cobimetinib (Cotellic ) Tablet
09-J2000-53 Original Effective Date: 03/15/16 Reviewed: 11/14/18 Revised: 12/15/18 Subject: Cobimetinib (Cotellic ) Tablet THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationSubject: Gefitinib (Iressa)
09-J2000-44 Original Effective Date: 09/15/15 Reviewed: 09/12/18 Revised: 10/15/18 Subject: Gefitinib (Iressa) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS,
More informationCaprelsa. Caprelsa (vandetanib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.16 Subject: Caprelsa Page: 1 of 5 Last Review Date: June 22, 2018 Caprelsa Description Caprelsa (vandetanib)
More informationSubject: Belinostat (Beleodaq ) Injection
09-J2000-21 Original Effective Date: 11/15/14 Reviewed: 01/09/19 Revised: 02/15/19 Subject: Belinostat (Beleodaq ) Injection THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationSubject: Pegvaliase-pqpz (Palynziq )
09-J3000-07 Original Effective Date: 09/15/18 Reviewed: 08/08/18 Revised: 10/15/18 Subject: Pegvaliase-pqpz (Palynziq ) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationSubject: Vemurafenib (Zelboraf )
09-J1000-40 Original Effective Date: 10/15/11 Reviewed: 12/12/18 Revised: 01/15/19 Next Review: 11/13/19 Subject: Vemurafenib (Zelboraf ) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationCAPRELSA (vandetanib) Tablets and Risk of QT Prolongation, Torsades de Pointes and Sudden Death
CAPRELSA (vandetanib) Tablets and Risk of QT Prolongation, Torsades de Pointes and Sudden Death Prescriber Training Pamphlet Introduction This training pamphlet has been developed as part of a REMS program
More informationSubject: Cannabidiol (Epidiolex )
09-J3000-08 Original Effective Date: 09/15/18 Reviewed: 08/08/18 Revised: 00/00/00 Next Review: 04/10/19 Subject: Cannabidiol (Epidiolex ) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationPrescriber Training Slide Deck
Prescriber Training Slide Deck 1 Contents Introduction CAPRELSA (vandetinib) Tablets Indication Risk of QT Prolongation, Torsades de pointes, and Sudden Death Patient Selection ECG and Electrolyte Monitoring
More informationSubject: Ondansetron HCl (Zofran ) Injection
09-J0000-98 Original Effective Date: 05/15/09 Reviewed: 07/10/13 Revised: 11/01/15 Subject: Ondansetron HCl (Zofran ) Injection THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationSubject: Sorafenib (Nexavar ) Tablets
09-J1000-50 Original Effective Date: 01/01/12 Reviewed: 12/12/18 Revised: 01/15/19 Next Review: 12/11/19 Subject: Sorafenib (Nexavar ) Tablets THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationSubject: Afatinib (Gilotrif ) Tablets
09-J2000-06 Original Effective Date: 12/15/13 Reviewed: 09/12/18 Revised: 10/15/18 Subject: Afatinib (Gilotrif ) Tablets THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationSubject: Palonosetron Hydrochloride (Aloxi )
09-J0000-87 Original Effective Date: 02/15/09 Reviewed: 07/09/14 Revised: 03/15/18 Subject: Palonosetron Hydrochloride (Aloxi ) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationCOMETRIQ (cabozantinib) oral capsule
COMETRIQ (cabozantinib) oral capsule Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy
More informationSubject: Alpha1-Proteinase Inhibitors (Human)
09-J0000-49 Original Effective Date: 01/01/05 Reviewed: 01/10/18 Revised: 02/15/18 Subject: Alpha1-Proteinase Inhibitors (Human) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationSubject: Ipilimumab (Yervoy ) Injection
09-J1000-34 Original Effective Date: 08/15/11 Reviewed: 03/14/18 Revised: 12/15/18 Subject: Ipilimumab (Yervoy ) Injection THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Caprelsa) Reference Number: CP.PHAR.80 Effective Date: 10.01.11 Last Review Date: 02.18 Line of Business: Health Insurance Marketplace, Medicaid Revision Log See Important Reminder at
More informationVotrient. Votrient (pazopanib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.83 Subject: Votrient Page: 1 of 6 Last Review Date: June 22, 2018 Votrient Description Votrient (pazopanib)
More informationSubject: Patisiran (Onpattro )
09-J3000-16 Original Effective Date: 12/15/18 Reviewed: 11/14/2018 Revised: 01/01/19 Subject: Patisiran (Onpattro ) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF
More information1-844-FAX-A360 ( )
1-844-ASK-A360 (1-844-275-2360) 1-844-FAX-A360 (1-844-329-2360) www.myaccess360.com For more information, call AstraZeneca Access 360 at 1-844-ASK-A360, Monday through Friday, 8 am to 8 pm ET. IMFINZI
More informationClinical Policy: Pazopanib (Votrient) Reference Number: ERX.SPA.139 Effective Date:
Clinical Policy: (Votrient) Reference Number: ERX.SPA.139 Effective Date: 03.01.14 Last Review Date: 08.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationCABOMETYX (cabozantinib) oral tablet
CABOMETYX (cabozantinib) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Pazopanib (Votrient) Reference Number: CP.PHAR.81 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the end
More informationNexavar. Nexavar (sorafenib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.60 Section: Prescription Drugs Effective Date: July 1,2017 Subject: Nexavar Page: 1 of 5 Last Review
More informationClinical Policy: Lenvatinib (Lenvima) Reference Number: CP.CPA.251 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: (Lenvima) Reference Number: CP.CPA.251 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important
More informationSubject: Eteplirsen (Exondys 51)
09-J2000-69 Original Effective Date: 10/15/16 Reviewed: 12/12/18 Revised: 01/01/19 Next Review: 12/11/18 Subject: Eteplirsen (Exondys 51) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationIressa. Iressa (gefitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Iressa Page: 1 of 5 Last Review Date: June 22, 2018 Iressa Description Iressa (gefitinib) Background
More informationSutent. Sutent (sunitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.95 Subject: Sutent Page: 1 of 6 Last Review Date: March 16, 2018 Sutent Description Sutent (sunitinib)
More informationRECENT MAJOR CHANGES. Warnings and Precautions (5.2) 0 7/2016
HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use CAPRELSA safely and effectively. See full prescribing information for CAPRELSA. CAPRELSA (vandetanib)
More informationGilotrif. Gilotrif (afatinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.39 Subject: Gilotrif Page: 1 of 6 Last Review Date: March 16, 2018 Gilotrif Description Gilotrif (afatinib)
More informationVotrient. Votrient (pazopanib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.83 Subject: Votrient Page: 1 of 6 Last Review Date: December 2, 2016 Votrient Description Votrient
More informationSubject: Everolimus (Afinitor, Afinitor Disperz ) Tablets
09-J1000-45 Original Effective Date: 01/01/12 Reviewed: 12/12/18 Revised: 01/15/19 Subject: Everolimus (Afinitor, Afinitor Disperz ) Tablets THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationNEXAVAR (sorafenib tosylate) oral tablet
NEXAVAR (sorafenib tosylate) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy
More informationTarceva. Tarceva (erlotinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.82 Subject: Tarceva Page: 1 of 5 Last Review Date: June 22, 2018 Tarceva Description Tarceva (erlotinib)
More informationClinical Policy: Sorafenib (Nexavar) Reference Number: CP.PHAR.69 Effective Date: Last Review Date: Line of Business: HIM, Medicaid
Clinical Policy: (Nexavar) Reference Number: CP.PHAR.69 Effective Date: 07.01.11 Last Review Date: 05.18 Line of Business: HIM, Medicaid Revision Log See Important Reminder at the end of this policy for
More informationSubject: Fosnetupitant-Palonosetron (Akynzeo) IV
09-J3000-01 Original Effective Date: 06/15/18 Reviewed: 05/09/18 Revised: 01/01/19 Subject: Fosnetupitant-Palonosetron (Akynzeo) IV THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationSubject: Capecitabine (Xeloda ) Tablets
09-J1000-42 Original Effective Date: 01/01/12 Reviewed: 12/13/17 Revised: 01/15/18 Subject: Capecitabine (Xeloda ) Tablets THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationCLINICAL MEDICAL POLICY
Policy Name: Policy Number: Approved By: Provider Notice Date: CLINICAL MEDICAL POLICY Portrazza (Necitumumab) MP-021-MD-WV Medical Management Original Effective Date: 06/02/2016 Annual Approval Date:
More informationCLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Policy Name: Avastin (bevacizumab) Policy Number: MP-030-MD-DE Responsible Department(s): Medical Management; Clinical Pharmacy Provider Notice Date: 10/01/2017 Original Effective
More information2. Treatment of patients with metastatic, squamous NSCLC progressing after platinumbased
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.39 Subject: Gilotrif Page: 1 of 5 Last Review Date: September 15, 2017 Gilotrif Description Gilotrif
More informationClinical Policy: Pazopanib (Votrient) Reference Number: CP.PHAR.81 Effective Date: 10/11
Clinical Policy: (Votrient) Reference Number: CP.PHAR.81 Effective Date: 10/11 Last Review Date: 12/16 Revision Log See Important Reminder at the end of this policy for important regulatory and legal information.
More informationSutent. Sutent (sunitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.95 Subject: Sutent Page: 1 of 5 Last Review Date: September 15, 2017 Sutent Description Sutent (sunitinib)
More informationCLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Policy Name: Faslodex (fulvestrant) Policy Number: MP-044-MD-DE Responsible Department(s): Medical Management; Clinical Pharmacy Provider Notice Date: 10/01/2017 Original Effective
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Iressa) Reference Number: CP.PHAR.68 Effective Date: 11.16.16 Last Review Date: 11.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy
More informationXALKORI (crizotinib) oral capsule
XALKORI (crizotinib) oral capsule Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage
More informationClinical Policy: Nilotinib (Tasigna) Reference Number: CP.CPA.162 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: (Tasigna) Reference Number: CP.CPA.162 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important
More informationCabozantinib for medullary thyroid cancer. February 2012
Cabozantinib for medullary thyroid cancer February 2012 This technology summary is based on information available at the time of research and a limited literature search. It is not intended to be a definitive
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Ipilimumab (Yervoy) Reference Number: CP.PHAR.319 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan Coding Implications Revision Log See Important
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Tagrisso) Reference Number: CP.PHAR.294 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this
More informationClinical Policy: Erlotinib (Tarceva) Reference Number: CP.PHAR74 Effective Date: Last Review Date: Line of Business: Oregon Health Plan
Clinical Policy: (Tarceva) Reference Number: CP.PHAR74 Effective Date: 07.01.18 Last Review Date: 02.18 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the end of this policy
More informationGilotrif. Gilotrif (afatinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.04.39 Subject: Gilotrif Page: 1 of 5 Last Review Date: September 12, 2014 Gilotrif Description Gilotrif
More informationRegulatory Status FDA-approved indication: Cabometyx is a kinase inhibitor indicated for the treatment of advanced renal cell carcinoma (1).
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.79 Subject: Cabometyx Page: 1 of 5 Last Review Date: March 16, 2018 Cabometyx Description Cabometyx
More informationTafinlar. Tafinlar (dabrafenib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.37 Subject: Tafinlar Page: 1 of 8 Last Review Date: September 20, 2018 Tafinlar Description Tafinlar
More informationTagrisso. Tagrisso (osimertinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.69 Subject: Tagrisso Page: 1 of 5 Last Review Date: September 15, 2016 Tagrisso Description Tagrisso
More informationClinical Policy: Pembrolizumab (Keytruda) Reference Number: CP.PHAR.322
Clinical Policy: (Keytruda) Reference Number: CP.PHAR.322 Effective Date: 03/17 Last Review Date: 03/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More informationImfinzi (durvalumab) (Intravenous)
Imfinzi (durvalumab) (Intravenous) Last Review Date: 09/05/2018 Date of Origin: 05/30/2017 Dates Reviewed: 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 09/2018 Document Number: IC-0301 I. Length of Authorization
More informationClinical Policy: Idelalisib (Zydelig) Reference Number: CP.CPA.278 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: (Zydelig) Reference Number: CP.CPA.278 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important
More informationXalkori. Xalkori (crizotinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.12 Subject: Xalkori Page: 1 of 6 Last Review Date: June 22, 2017 Xalkori Description Xalkori (crizotinib)
More informationDOSING GUIDE. Indications. Important Safety Information. Enable the immune system. RECOGNIZE. RESPOND.
DOSING GUIDE For patients with unresectable Stage III NSCLC following concurrent CRT For patients with locally advanced or metastatic UC previously treated with platinum-based therapy Enable the immune
More informationGILOTRIF (afatinib) oral tablet
GILOTRIF (afatinib) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage
More informationClinical Policy: Nivolumab (Opdivo) Reference Number: CP.PHAR.121
Clinical Policy: (Opdivo) Reference Number: CP.PHAR.121 Effective Date: 07/15 Last Review Date: 04/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More informationSubject: Chemoresistance and Chemosensitivity Assays
05-86000-11 Original Effective Date: 12/15/02 Reviewed: 09/27/18 Revised: 10/15/18 Subject: Chemoresistance and Chemosensitivity Assays THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationNational Horizon Scanning Centre. Vandetanib (Zactima) for locally advanced or metastatic medullary thyroid cancer. December 2007
Vandetanib (Zactima) for locally advanced or metastatic medullary thyroid cancer December 2007 This technology summary is based on information available at the time of research and a limited literature
More informationALUNBRIG (brigatinib) Dosing Guide
ALUNBRIG (brigatinib) Dosing Guide INDICATION ALUNBRIG (brigatinib) is indicated for the treatment of patients with anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC)
More informationSubject: Dasatinib (Sprycel ) Tablets
09-J1000-43 Original Effective Date: 01/01/12 Reviewed: 01/10/18 Revised: 02/15/18 Subject: Dasatinib (Sprycel ) Tablets THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationClinical Policy: Regorafenib (Stivarga) Reference Number: CP.PHAR.107 Effective Date: 12/12 Last Review Date: 11/16
Clinical Policy: (Stivarga) Reference Number: CP.PHAR.107 Effective Date: 12/12 Last Review Date: 11/16 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Darbepoetin Alfa (Aranesp) Reference Number: CP.PHAR.236 Effective Date: 06.01.16 Last Review Date: 05.18 Line of Business: HIM, Medicaid Coding Implications Revision Log See Important
More informationClinical Policy: Ramucirumab (Cyramza) Reference Number: CP.PHAR.119
Clinical Policy: (Cyramza) Reference Number: CP.PHAR.119 Effective Date: 05/15 Last Review Date: 04/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More informationVandetanib. ICD-10 codes Codes with a pre-fix C73.
Vandetanib Indication First line treatment of histologically confirmed, unresectable, locally advanced or metastatic medullary thyroid cancer in patients with progressive and symptomatic disease. ICD-10
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Lotronex) Reference Number: CP.PMN.153 Effective Date: 11.16.16 Last Review Date: 11.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy
More informationSubject: Edaravone (Radicava)
09-J2000-82 Original Effective Date: 09/15/17 Reviewed: 12/12/18 Revised: 01/15/19 Next Review: 12/11/19 Subject: Edaravone (Radicava) THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Transmucosal Immediate Release Fentanyl Products Reference Number: CP.CPA.211 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder
More information2. Treatment of patients with metastatic, squamous NSCLC progressing after platinumbased
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.39 Subject: Gilotrif Page: 1 of 5 Last Review Date: June 24, 2016 Gilotrif Description Gilotrif (afatinib)
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Abraxane) Reference Number: CP.PHAR.176 Effective Date: 07.01.15 Last Review Date: 05.18 Line of Business: HIM, Medicaid Coding Implications Revision Log See Important Reminder at the
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Transmucosal Immediate Release Fentanyl Products Reference Number: CP.HNMC.211 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important
More informationUnitedHealthcare Pharmacy Clinical Pharmacy Programs
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2017 P 1101-7 Program Prior Authorization/Notification Medication Sutent (sunitinib malate) P&T Approval Date 8/2008, 6/2009, 6/2010,
More informationCLINICAL MEDICATION POLICY
Policy Name: Policy Number: Approved By: CLINICAL MEDICATION POLICY Adcetris (Brentuximab Vedotin) MP-035-MD-WV Provider Notice Date: 07/03/2017 Original Effective Date: 08/03/2017 Annual Approval Date:
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Sutent) Reference Number: CP.PHAR.73 Effective Date: 09.01.11 Last Review Date: 05.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of this
More informationSubject: NK-1 receptor antagonist injectable therapy (Emend, Cinvanti, Varubi )
09-J2000-60 Original Effective Date: 06/15/16 Reviewed: 04/11/18 Revised: 01/01/19 Subject: NK-1 receptor antagonist injectable therapy (Emend, Cinvanti, Varubi ) THIS MEDICAL COVERAGE GUIDELINE IS NOT
More informationALUNBRIG (brigatinib) oral tablet
ALUNBRIG (brigatinib) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage
More informationTARCEVA (erlotinib) oral tablet
TARCEVA (erlotinib) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage
More informationCLINICAL POLICY Department: Medical Management Document Name: Inlyta Reference Number: NH.PHAR.100 Effective Date: 05/12
Page: 1 of 5 IMPORTANT REMINDER This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted
More informationVandetanib in Thyroid carcinoma
REGIMEN TITLE: Vandetanib in Thyroid carcinoma Page 1 of 6 Indication: Medullary thyroid carcinoma NHS England CDF criteria to be met (CDF funding approval required): Locally advanced and unresectable
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Portrazza) Reference Number: CP.PHAR.320 Effective Date: 03.01.17 Last Review Date: 11.18 Line of Business: Medicaid, HIM-Medical Benefit Coding Implications Revision Log See Important
More informationUnitedHealthcare Pharmacy Clinical Pharmacy Programs
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2017 P 1113-6 Program Prior Authorization/Notification Medication Votrient TM (pazopanib) P&T Approval Date 1/12/2010, 9/2010, 12/2010,
More informationacceptance of PFS as a clinically meaningful endpoint and its agreement with the CGP that PFS is a likely surrogate of OS in MTC.
acceptance of PFS as a clinically meaningful endpoint and its agreement with the CGP that PFS is a likely surrogate of OS in MTC. perc deliberated upon the cost-effectiveness of vandetanib and concluded
More informationPortrazza. Portrazza (necitumumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.72 Subject: Portrazza Page: 1 of 5 Last Review Date: September 15, 2017 Portrazza Description Portrazza
More informationSubject: Prostate Saturation Biopsy
02-54000-22 Original Effective Date: 01/01/10 Reviewed: 09/27/18 Revised: 10/15/18 Subject: Prostate Saturation Biopsy THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationNCCP Chemotherapy Regimen. PAZOPanib Therapy
INDICATIONS FOR USE: PAZOPanib Therapy Regimen Code INDICATION ICD10 First line treatment of advanced Renal Cell Carcinoma (RCC) in adults and for C64 00445a patients who have received prior cytokine therapy
More informationCorporate Medical Policy
Corporate Medical Policy Molecular Analysis for Targeted Therapy for Non-Small Cell Lung File Name: Origination: Last CAP Review: Next CAP Review: Last Review: molecular_analysis_for_targeted_therapy_for_non_small_cell_lung_cancer
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Crinone, Endometrin) Reference Number: CP.CPA.03 Effective Date: 11.16.16 Last Review Date: 08.18 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy
More informationDescription of Procedure or Service. Policy. Benefits Application
Corporate Medical Policy KRAS, NRAS, BRAF Mutation Analysis and Related File Name: Origination: Last CAP Review: Next CAP Review: Last Review: kras_nras_braf_mutation_analysis_and_related_treatment_in_metastatic_colorectal_cancer
More informationCLINICAL MEDICATION POLICY
Policy Name: Policy Number: Approved By: CLINICAL MEDICATION POLICY Adcetris (brentuximab vedotin) MP-035-MD-DE Provider Notice Date: 08/01/2017 Original Effective Date: 09/01/2017 Annual Approval Date:
More informationStivarga. Stivarga (regorafenib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.26 Subject: Stivarga Page: 1 of 5 Last Review Date: September 15, 2017 Stivarga Description Stivarga
More informationZURAMPIC (lesinurad) oral tablet
ZURAMPIC (lesinurad) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: No Coverage Criteria/Off-Label Use Policy Reference Number: CP.PMN.53 Effective Date: 07.01.18 Last Review Date: 05.01.18 Line of Business: Oregon Health Plan Revision Log See Important
More informationPRODUCT MONOGRAPH CAPRELSA. Vandetanib tablets. 100 and 300 mg. Receptor tyrosine kinase inhibitor
PRODUCT MONOGRAPH CAPRELSA Vandetanib tablets 100 and 300 mg Receptor tyrosine kinase inhibitor Sanofi Genzyme, a division of sanofi-aventis Canada Inc. 800-2700 Matheson Blvd East Mississauga, ON L4W
More informationClinical Policy: Nivolumab (Opdivo) Reference Number: CP.PHAR.121 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Opdivo) Reference Number: CP.PHAR.121 Effective Date: 07.15 Last Review Date: 01.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
More informationPROLIA: Medical Coverage Policy Denosumab (Prolia and. Xgeva) EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Denosumab (Prolia and Xgeva) EFFECTIVE DATE: 11 01 2016 POLICY LAST UPDATED: 12 19 2017 OVERVIEW Prolia (denosumab) is indicated for the treatment of postmenopausal women with osteoporosis
More information