Caprelsa (vandetanib) — CareFirst (Caremark)
Thyroid carcinoma (follicular, oncocytic/Hürthle cell, papillary, or medullary)
Initial criteria
- Authorization may be granted for treatment of thyroid carcinoma when any of the following are met:
- • Member has follicular, oncocytic/Hürthle cell, or papillary thyroid carcinoma that is not amenable to radioactive iodine (RAI) therapy.
- • Member has medullary thyroid carcinoma.
Reauthorization criteria
- Authorization 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