Medical Policy

Effective Date:08/01/2017 Title:Sutent (Sunitinib)
Revision Date: Document:BI550:00
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)    Sutent (Sunitinib) requires prior authorization.

2)    Sutent is used to treat a number of different types of cancer.

3)    Sutent is an oral specialty drug covered under the pharmacy benefit.

Medical Statement

Sutent (sunitinib) is considered medically necessary for members meeting the following criteria for the different conditions below.

 

1)    Gastrointestinal Stromal Tumor (GIST)

a.     Diagnosis of gastrointestinal stromal tumor (GIST); AND

b.     History of failure, contraindication, or intolerance to Gleevec (imatinib)

2)    Renal Cell Carcinoma (RCC)

a.     Diagnosis of renal cell carcinoma; AND

b.     One of the following

                                                    i.     Disease has relapsed; OR

                                                   ii.     Stage IV disease with unresectable tumor

 

3)    Islet Cell Tumors / Progressive Pancreatic Neuroendocrine Tumors (pNET)

a.     Diagnosis of islet cell tumor / progressive pancreatic neuroendocrine tumors (pNET)

 

4)    Soft Tissue Sarcoma

a.     Diagnosis of one of the following:

                                                    i.     Alveolar soft part sarcoma (ASPS)

                                                   ii.     Angiosarcoma

                                                 iii.     Solitary fibrous tumor / hemangiopericytoma

 

5)    Thyroid Carcinoma

a.     Diagnosis of one of the following; AND

                                                    i.     Follicular carcinoma

                                                   ii.     Hurthle cell carcinoma

                                                 iii.     Papillary carcinoma

b.     One of the following; AND

                                                    i.     Unresectable recurrent disease

                                                   ii.     Persistentlocoregional disease

                                                 iii.     Metastatic disease

c.     One of the following; AND

                                                    i.     Patient has symptomatic disease

                                                   ii.     Patient has progressive disease

d.     Disease is refractory to radioactive iodine therapy

 

OR

e.     Diagnosis of medullary thyroid carcinoma; AND

f.      Patient has progressive or symptomatic metastatic disease; AND

g.     History of failure, contraindication, or intolerance to one of the following:

                                                    i.     Caprelsa (vandetanib)

                                                   ii.     Cometriq (Cabozantinib)

 

6)    Chordoma

a.     Diagnosis of recurrent Chordoma

 

7)    Central Nervous System Cancer

a.     Diagnosis of surgically inaccessible meningiomas; AND

b.     Recurrent or progressive disease; AND

c.     Further radiation is not possible

 

 

8)    Thymic Carcinoma

a.     Diagnosis of Thymic carcinoma; AND

b.     Used as second-line following a failure, contraindication, or intolerance to a first-line chemotherapy regimen (e.g. carboplatin/paclitaxel)

Limits

As an oral specialty drug, Sutent is limited to a maximum 30-day supply per fill and must be obtained through a contracted specialty pharmacy.

Reference

1)    Clinical Pharmacology. Accessed online 7/17/2017

2)    NCCN Drugs and Biologics Compendium.  Accessed online 7/17/2017.

Application to Products
This policy applies to all health plans 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) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, 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.