Pharmacy Prior Authorization Criteria

Stivarga (regorafenib)

For diagnosis of Metastatic Colorectal Cancer (mCRC)
Indicated for the treatment of patients with metastatic colorectal cancer (CRC) who have been previously treated with fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapy, an anti-VEGF therapy, and, if RAS wild- type, an anti-EGFR therapy.
For diagnosis of Gastrointestinal Stromal Tumor (GIST)
Indicated for the treatment of patients with locally advanced, unresectable or metastatic gastrointestinal stromal tumor (GIST) who have been previously treated with imatinib mesylate and sunitinib malate.
For diagnosis of Hepatocellular Carcinoma (HCC)
Indicated for the treatment of patients with hepatocellular carcinoma (HCC) who have been previously treated with sorafenib.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Metastatic Colorectal Cancer (mCRC) [1,2]

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Gastrointestinal Stromal Tumor (GIST) [1,2]

AND

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Hepatocellular Carcinoma (HCC) [1,2]

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of All Indications Listed Above

2024-05-20, 2023-07-05, 2023-05-24, 2023-05-04, 2022-05-22, 2021-08-02, 2021-05-11, 2020-06-02, 2019-11-24

Stivarga Prescribing Information. Bayer HealthCare Pharmaceuticals Inc., December 2020.
The NCCN Drugs and Biologics Compendium (NCCN Compendium™). Available at http://www.nccn.org/professionals/drug_compendium/content/contents.asp. Accessed April 19, 2022.