ERIVEDGE (vismodegib)

ERIVEDGE (vismodegib)

Self Administration - Oral

Indications for Prior Authorization:

• 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.

Coverage Criteria:

For diagnosis of basal cell carcinoma:

• Dose does not exceed 150 mg per day; AND
• Patient is 18 years of age or older; AND
• Prescribed by or in consultation with dermatologist or oncologist; AND
• One of the following:
  • Diagnosis of metastatic basal cell carcinoma, OR
  • Diagnosis of locally advanced basal cell carcinoma and one of the following:
    • Disease recurred following surgery.
    • Patient is not a candidate for surgery.
    • Patient is not a candidate for radiation.

Reauthorization Criteria:

For diagnosis of basal cell carcinoma:

• Dose does not exceed 150 mg once daily; AND
• Patient does not show evidence of progressive disease while on therapy.

Coverage Duration:

• Initial: 1 year
• Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information:

• Erivedge has off-label support in NCCN (2A) to treat medulloblastoma for patients who have received prior chemotherapy with a mutation in the sonic hedgehog pathway.

Policy Updates:

• 08/17/2021 – New criteria for existing drug with prior authorization approved by P&T.

Refrences:

• Erivedge Prescribing Information. Genentech USA Inc. South San Francisco, CA. February 2019.
• The NCCN Drugs and Biologics Compendium (NCCN Compendium). Available at http://www.nccn.org/professionals/drug_compendium/content/contents.asp. Accessed August 4, 2020.