Pharmacy Prior Authorization Criteria

Cometriq (cabozantinib)

Indications for Prior Authorization

Cometriq (cabozantinib)

• For diagnosis of Medullary thyroid cancer
  Indicated for the treatment of patients with progressive, metastatic medullary thyroid cancer (MTC).

• For diagnosis of Non-small cell lung cancer
  Has activity against RET gene rearrangements in non-small cell lung cancer (NSCLC). [3]

Criteria

Cometriq

If patient meets criteria above, please approve at GPI-12.

Prior Authorization (Initial Authorization)

Length of Approval: 11 months [A]
For diagnosis of Medullary Thyroid Cancer (MTC)

• Diagnosis of one of the following: [1,2]
• Metastatic medullary thyroid cancer (MTC)
• Unresectable locally advanced MTC
AND
• One of the following: [2]
• Patient has symptomatic disease
• Patient has progressive disease

Cometriq

If patient meets criteria above, please approve at GPI-12.

Prior Authorization (Reauthorization)

Length of Approval: 11 months [A]
For diagnosis of Medullary Thyroid Cancer (MTC)

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

Cometriq

If patient meets criteria above, please approve at GPI-12.

Prior Authorization (Initial Authorization)

Length of Approval: 11 months [A]
For diagnosis of Non-Small Cell Lung Cancer (NSCLC) (off-label)

• Diagnosis of non-small cell lung cancer (NSCLC) [3]
AND
• Presence of RET gene rearrangements as detected by a U.S. Food and Drug Administration (FDA)-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA) [3]

Cometriq

If patient meets criteria above, please approve at GPI-12.

Prior Authorization (Reauthorization)

Length of Approval: 11 months [A]
For diagnosis of Non-Small Cell Lung Cancer (NSCLC) (off-label)

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

P & T Revisions

2024-09-27, 2024-09-12, 2023-10-02, 2023-06-13, 2022-10-03, 2021-09-09, 2021-05-20, 2021-04-14, 2020-09-30, 2019-08-27, 2019-08-27

References

1. Cometriq prescribing information. Exelixis, Inc. Alameda, CA. August 2023.
2. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Thyroid Carcinoma. v4.2024. Available by subscription at: https://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf. Accessed on September 16, 2024.
3. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Non-Small Cell Lung Cancer v9.2024. Available by subscription at: https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed on September 16, 2024.

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End Notes

1. In a phase 3 clinical trial of 330 patients, a statistically significant prolongation in progression free survival (PFS) was demonstrated among Cometriq-treated patients compared to those receiving placebo, with a median PFS time of 11.2 months and 4 months in the Cometriq and placebo arms, respectively. [1]

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Revision History

• 2024-09-27: 2024 Annual Review. Revised genetic testing criteria to standard verbiage. Background updates
• 2024-09-12: No changes to criteria. Added operational note.
• 2023-10-02: Annual review: No criteria changes. Updated references.
• 2023-06-13: guideline update
• 2022-10-03: Annual review: No criteria changes, updated references.
• 2021-09-09: annual review: updated references
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2021-04-14: Updated GPIs
• 2020-09-30: Annual Review: update references
• 2019-08-27: updated revision date for P&T
• 2019-08-27: Annual review - no updates to clinical criteria except removing the drug name from reauthorization criteria & reference updates

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