axitinib — CareFirst (Caremark)

Initial criteria

• Authorization of 12 months may be granted for treatment of advanced, relapsed, or stage IV renal cell carcinoma when any of the following criteria is met:
• • Inlyta will be used as a single agent
• • Inlyta will be used in combination with pembrolizumab
• • Inlyta will be used as first-line treatment in combination with avelumab

Reauthorization criteria

• Authorization of 12 months may be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Approval duration

12 months