Votrient (pazopanib) — United Healthcare

Initial criteria

• Diagnosis of one of the following: Angiosarcoma; Alveolar soft part sarcoma; Pleomorphic rhabdomyosarcoma; Retroperitoneal/Intra-abdominal disease that is unresectable, stage IV, or postoperative treatment for residual disease; Soft Tissue Sarcoma of the Extremity/Superficial Trunk or Head/Neck with disease that is stage IV or recurrent and has disseminated metastases; Solitary fibrous tumor/hemangiopericytoma; Desmoid tumors (aggressive fibromatosis); Dermatofibrosarcoma Protuberans (DFSP) with Fibrosarcomatous Transformation; Dedifferentiated Chordoma; Epithelioid hemangioendothelioma; Extraskeletal myxoid chondrosarcoma

Reauthorization criteria

• Patient does not show evidence of progressive disease while on Votrient therapy

Approval duration

12 months