Pharmacy Prior Authorization Criteria

Pedmark (sodium thiosulfate injection, solution)

Indications for Prior Authorization

Pedmark (sodium thiosulfate injection, solution)

• For diagnosis of Prophylaxis of Cisplatin-Induced Ototoxicity.
  Indicated to reduce the risk of ototoxicity associated with cisplatin in pediatric patients 1 month of age and older with localized, non-metastatic solid tumors. Limitations of Use: The safety and efficacy of Pedmark have not been established when administered following cisplatin infusions longer than 6 hours. Pedmark may not reduce the risk of ototoxicity when administered following longer cisplatin infusions, because irreversible ototoxicity may have already occurred.

Criteria

Pedmark

Prior Authorization

Length of Approval: 12 Month(s)

• Diagnosis of solid tumors
AND
• Disease is BOTH of the following:
• Localized
• Non-Metastatic
AND
• Used for the prevention of ototoxicity due to cisplatin-based chemotherapy
AND
• Patient is 1 month of age or older
AND
• Prescribed by or in consultation with an oncologist

P & T Revisions

2024-11-01, 2022-11-21

References

1. Pedmark Prescribing Information. Fennec Pharmaceuticals, Inc. Hoboken, NJ. September 2022.
2. Clinical Consult - Pediatric Hematology/Oncology specialist. November 15, 2022.

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Revision History

• 2024-11-01: Annual review - no criteria changes.
• 2022-11-21: New UM PA Criteria

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