Pharmacy Prior Authorization Criteria

Caprelsa (vandetanib)

Indications for Prior Authorization

Caprelsa (vandetanib)

• For diagnosis of Medullary Thyroid Cancer (MTC)
  Indicated for the treatment of symptomatic or progressive MTC in patients with unresectable locally advanced or metastatic disease.

  Use Caprelsa in patients with indolent, asymptomatic or slowly progressing disease only after careful consideration of the treatment related risks of Caprelsa.

Criteria

Caprelsa

Prior Authorization (Initial Authorization)

Length of Approval: 12 Months

• Diagnosis of one of the following:
• Metastatic medullary thyroid cancer (MTC)
• Unresectable locally advanced MTC
AND
• One of the following:
• Patient has symptomatic disease
• Patient has progressive disease

Caprelsa

Prior Authorization (Reauthorization)

Length of Approval: 12 Months

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

P & T Revisions

2024-09-04, 2023-09-01, 2023-07-18, 2022-09-07, 2021-08-03, 2021-05-20, 2021-04-14, 2020-08-27, 2019-08-12

References

1. Caprelsa prescribing information. Genzyme Corporation. Cambridge, MA. April 2024.

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Revision History

• 2024-09-04: Annual review: No criteria changes. Updated references.
• 2023-09-01: Annual review: No criteria changes. Updated references.
• 2023-07-18: Removed Oncologist specialist requirement
• 2022-09-07: Annual review: No criteria changes. Updated references.
• 2021-08-03: Annual review: updated references, no criteria changes
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2021-04-14: Updated GPIs
• 2020-08-27: Annual Review: updated references and removed drug name from reauthorization
• 2019-08-12: no changes to clinical criteria annual review update

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