Pharmacy Prior Authorization Criteria

Fotivda (tivozanib) - PA, NF

Indications for Prior Authorization

Fotivda (tivozanib)

• For diagnosis of Renal cell carcinoma (RCC)
  Indicated for the treatment of adult patients with relapsed or refractory advanced renal cell carcinoma (RCC) following two or more prior systemic therapies.

Criteria

Fotivda

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Renal cell carcinoma (RCC)

• Diagnosis of advanced renal cell carcinoma (RCC)
AND
• Disease is one of the following:
• Relapsed
• Refractory
AND
• Patient has received two or more prior systemic therapies (e.g., chemotherapy)

Fotivda

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Renal cell carcinoma (RCC)

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

Fotivda

Non Formulary

Length of Approval: 12 Month(s)
For diagnosis of Renal cell carcinoma (RCC)

• Diagnosis of advanced renal cell carcinoma (RCC)
AND
• Disease is one of the following:
• Relapsed
• Refractory
AND
• Patient has received two or more prior systemic therapies (e.g., chemotherapy)

P & T Revisions

2024-05-21, 2023-06-26, 2023-05-03, 2022-04-07, 2022-01-04, 2021-06-16

References

1. Fotivda Prescribing Information. AVEO Pharmaceuticals, Inc. Boston, MA. March 2021.
2. The NCCN Drugs and Biologics Compendium (NCCN Compendium™). Available at https://www.nccn.org/professionals/drug_compendium/content/. Accessed April 5, 2024.

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Revision History

• 2024-05-21: 2024 annual review: Updated diagnosis to say "diagnosis of advanced renal cell carcinoma" to align with FDA-approved label.
• 2023-06-26: Removed specialist requirement.
• 2023-05-03: Annual review: Replaced examples of systemic therapy with "chemotherapy." Updated references.
• 2022-04-07: Annual review: No criteria changes, updated references.
• 2022-01-04: Added specific NF sections that mirror initial PA since its excluded on Premium
• 2021-06-16: New program.

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