Pharmacy Prior Authorization Criteria

Odomzo (sonidegib)

Indications for Prior Authorization

Odomzo (sonidegib)

• For diagnosis of Locally advanced basal cell carcinoma (BCC)
  Indicated for the treatment of adult patients with locally advanced basal cell carcinoma (BCC) that has recurred following surgery or radiation therapy, or those who are not candidates for surgery or radiation therapy.

Criteria

Odomzo

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Basal Cell Carcinoma

• Diagnosis of locally advanced basal cell carcinoma [2]
AND
• One of the following:
• Cancer has recurred following surgery or radiation therapy
• Patient is not a candidate for surgery or radiation therapy

Odomzo

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Basal Cell Carcinoma

• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2024-08-07, 2023-09-01, 2023-07-18, 2022-09-08, 2021-09-17, 2021-05-21, 2020-08-10

References

1. Odomzo Prescribing Information. Sun Pharmaceutical Industries, Inc. Cranbury, NJ. August 2023.
2. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Basal Cell Skin Cancer. v.3.2024. Available at: https://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf. Accessed August 7, 2024.
3. Per clinical consult with oncologist, February 24, 2011.

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Revision History

• 2024-08-07: 2024 Annual Review. Background changes.
• 2023-09-01: Annual Review - no criteria changes
• 2023-07-18: Removed oncologist specialist requirement
• 2022-09-08: Annual Review - No criteria updates
• 2021-09-17: 2021 annual review: no criteria changes.
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2020-08-10: Annual Review - No changes

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