Medical Policy

Effective Date:04/01/2013 Title:Cometriq (Cabozanitinib)
Revision Date:08/01/2018 Document:BI402:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Cometriq and Cabometyx (Cabozanitinib) require prior authorization.

2)    Cometriqis used to treat a specific type of thyroid cancer and Cabometyx is used to treat advanced kidney cancer.

3)    Cometriq and Cabometyx must be obtained through the specified specialty pharmacy.

Medical Statement

Cometriq or Cabometyx (Cabozanitinib) is considered medically necessary for patients meeting the following criteria. Initial approval is for three (3) months.  Subsequent approvals will be for additional 3 month periods upon providing documentation there has been no disease progression while on therapy.  If disease progression occurs while on Cabozanitinib therapy, drug should be discontinued.

 

Cometriq for Thyroid Cancer:

1)    Diagnosis of progressive, metastatic medullary, follicular, or Hurthle cell thyroid cancer and has none of the following exclusions to therapy (gastrointestinal perforation, fistula, or severe hemorrhage)

 

Cabometyx for Renal Cell Cancer:

1)    Diagnosis of advanced renal cell cancer AND

2)    Relapsed or surgically unresectable stage IV disease

Limits

As a specialty drug, Cometriq or Cabometyx is limited to no more than a 30 day supply at one time.

Reference

1)    Cometriq prescribing information.  Exelixis Inc., South San Francisco, CA; November 2012.

2)    Almeida MQ, Hoff AO. Recent Advances in the Molecular Pathogenesis and Targeted Therapies of Medullary Thyroid Carcinoma. CurrOpin Oncol. 2012; 24:229-234.

3)    NCCN Drugs & Biologics Compendium.  Accessed online 5/13/2016.

4)    Clinical Pharmacology. Accessed online 5/13/2016.

Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.