axitinib — CareFirst (Caremark)

Initial criteria

• Authorization of 12 months may be granted for treatment of alveolar soft part sarcoma (ASPS) subtype of soft tissue sarcoma when used in combination with pembrolizumab.

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