CurrentCignaPolicy N/A

Oncology - Pazopanib Preferred Specialty Management Policy

Defines Cigna's Preferred Specialty Management program for pazopanib, specifying preferred (generic) versus non-preferred (brand Votrient) products, prior authorization and exception criteria affecting coverage for members under Cigna-administered plans.

Policy Summary

PayerCigna

PolicyOncology - Pazopanib Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 15, 2024

Next Review DateN/A

Key ActionObtain and document prior authorization per the Oncology - Pazopanib Prior Authorization Policy and verify trial of generic pazopanib before approving brand Votrient.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearStandard approval duration

genericPreferred product

Non-PreferredVotrient status

requiredPrior authorization

Coverage Criteria for Votrient (brand pazopanib)

Non-Preferred Product Exception Criteria (Votrient)

Votrient (brand pazopanib) is covered as medically necessary when ALL of the following are met:

Votrient exception criteria: A) Patient meets the standard Oncology - Pazopanib Prior Authorization Policy criteria; AND B) Patient has tried generic pazopanib tablets (documentation required); AND C) Patient cannot take pazopanib due to a formulation difference in inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) between the brand and bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction (documentation required).

Approve for 1 year if all conditions met

Approval of Preferred Product when exception criteria not met

If the patient meets standard prior authorization criteria but has not met the exception criteria for Votrient:

Fallback to preferred product: Approve generic pazopanib tablets if exception criteria (trial of generic and formulation-based intolerance) for brand Votrient are not met.

Policy Summary

PayerCigna

PolicyOncology - Pazopanib Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 15, 2024

Next Review DateN/A

Key ActionObtain and document prior authorization per the Oncology - Pazopanib Prior Authorization Policy and verify trial of generic pazopanib before approving brand Votrient.

SourceLink

On This Page

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Approvals are provided for 1 year; documentation of prior authorization and trial of preferred product may be required.

Any exception request to approve the non-preferred product Votrient other than the specific formulation-difference allergy/intolerance described in the exception criteria is considered not medically necessary.

Requests for non-preferred Votrient that do not meet all of the specified exception criteria (trial of generic pazopanib tablets and documented inability to take the generic because of a formulation difference in inactive ingredients causing a significant allergy or serious adverse reaction) are considered not medically necessary.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

All pazopanib medications (preferred and non-preferred) require prior authorization under the standard Oncology - Pazopanib Prior Authorization Policy. Requests that lack the required prior authorization or do not meet the Oncology - Pazopanib Prior Authorization Policy criteria are subject to denial.

Applies to all pazopanib products (preferred generic pazopanib tablets and non-preferred Votrient)
Approvals are provided for 1 year when criteria are met

Step Therapy

Preferred-before-Nonpreferred Requirement

Patients should try the preferred generic pazopanib product before approval of the non-preferred brand product Votrient. If the patient meets the standard Oncology - Pazopanib Prior Authorization Policy criteria but has not tried a preferred product, approval will be authorized for the preferred product. Requests for Votrient require documentation that the preferred product was tried and/or an exception justification per the non-preferred product exception criteria.

Preferred product: generic pazopanib tablets
Non-preferred product: Votrient
If standard PA criteria are met but preferred product not tried, approval will be for the preferred product
Exceptions for Votrient require meeting the Non-Preferred Product Exception Criteria (including documented trial of generic pazopanib or documented intolerance/clinical justification)

Definitions

Pazopanib (definition and context)

AgentPazopanib (multi-tyrosine kinase inhibitor)

IndicationsAdvanced renal cell carcinoma in adults; advanced soft tissue sarcoma in adults who have received prior chemotherapy

Brand/Preferred ContextPolicy distinguishes generic pazopanib (preferred) from brand Votrient (non-preferred); exceptions permit Votrient only when criteria met

Typical approval durationApprove for 1 year when exception criteria are met

Documentation requiredDocumentation required to support trial of generic pazopanib and any formulation-related allergy or serious adverse reaction when requesting Votrient

Line of Therapy Notes

first-line

Indications listed: Advanced renal cell carcinoma; advanced soft tissue sarcoma in adults who have received prior chemotherapy.

Indications per drug labeling

Background

Pazopanib is a multi-tyrosine kinase inhibitor indicated for advanced renal cell carcinoma in adults and for advanced soft tissue sarcoma in adults who have received prior chemotherapy. The policy differentiates between the preferred product (generic pazopanib tablets) and the non-preferred brand product Votrient for coverage and prior authorization purposes.