Medical Policy

Effective Date:08/03/2011 Title:Caprelsa (Vandetanib)
Revision Date:10/01/2014 Document:BI311:00
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)    Caprelsa (Vandetanib) requires prior authorization.

2)    (Caprelsa) Vandetanib is used to treat a specific type of thyroid cancer.

Medical Statement

Caprelsa (Vandetanib) is considered medically necessary for patients who meet the following criteria:

1)    Diagnosis of symptomatic or progressive medullary thyroid cancer with unresectable local or metastatic disease AND

2)    Patient does not have congenital long QT syndrome

Limits

As a specialty drug, Caprelsa (Vendetanib) is limited to no more than a 30-day supply at one time.

Reference

 

1)    Caprelsa Product Information.  Astra-Zeneca 2011

2)    Wells Jr SA, Gosnell JE, Gagel RF, et al.  Vandetanib for the treatment of patients with locally advanced or metastatic hereditary medullary thyroid cancer.  J of Clin Oncology. 28:767-772, 2010.

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.