Pharmacy Prior Authorization Criteria

Erivedge (vismodegib)

Indications for Prior Authorization

Erivedge (vismodegib)

• For diagnosis of Basal cell carcinoma
  Indicated for the treatment of adults with metastatic basal cell carcinoma, or with locally advanced basal cell carcinoma that has recurred following surgery or who are not candidates for surgery, and who are not candidates for radiation.

Criteria

Erivedge

Prior Authorization (Initial Authorization)

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

• One of the following:
• Diagnosis of metastatic basal cell carcinoma
OR
• Both of the following:
• Diagnosis of locally advanced basal cell carcinoma
AND
• One of the following:
• Disease recurred following surgery
• Patient is not a candidate for both surgery and radiation

Erivedge

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

2024-08-14, 2023-08-31, 2023-06-15, 2022-09-09, 2021-08-26, 2021-05-19, 2020-09-01, 2019-08-09

References

1. Erivedge Prescribing Information. Genentech USA Inc. South San Francisco, CA. August 2020.
2. The NCCN Drugs and Biologics Compendium (NCCN Compendium). Available at http://www.nccn.org/professionals/drug_compendium/content/contents.asp. Accessed August 4, 2020..

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End Notes

1. Verified with consultant that other specialists such as Dermatologists may prescribe vismodegib in addition to Oncologists. [3]
2. Based on the vismodegib pivotal study, the median duration of treatment was approximately 10 months (305 days; range 0.7 to 36 months); 111 patients received vismodegib for 6 months or longer. [1]

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Revision History

• 2024-08-14: 2024 Annula Review.
• 2023-08-31: Annual Review - No criteria changes
• 2023-06-15: Removal of specialist requirement
• 2022-09-09: Annual Review - reauth verbiage updated to include "while on therapy". Patient characteristics updated to require patient is not a candidate for both surgery AND radiation.
• 2021-08-26: Annual Review
• 2021-05-19: Addition of EHB formulary to guideline, no changes to criteria
• 2020-09-01: 2020 Annual Review. No change to criteria, background updates only.
• 2019-08-09: Annual review. No changes to clinical criteria. Updated references. XC 8/9/19.

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