Erivedge (vismodegib) — Highmark

Initial criteria

• age ≥ 18 years
• Diagnosis of basal cell carcinoma (ICD-10: C44.01-C44.92)
• Disease is metastatic OR disease is locally advanced AND disease has recurred after surgery or the member is not a candidate for surgery AND the member is not a candidate for radiation

Reauthorization criteria

• Prescriber attests that the member is tolerating therapy and has experienced a therapeutic response defined as disease improvement or delayed disease progression

Approval duration

12 months