vismodegib — CareFirst (Caremark)

Initial criteria

• Authorization may be granted for treatment of recurrent adult medulloblastoma in patients who have received prior systemic therapy and whose tumor(s) have mutations in the sonic hedgehog pathway, as a single agent.

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