CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Caprelsa (vandetanib) for Thyroid Carcinoma — Coverage Criteria

Covers use of Caprelsa (vandetanib) for FDA‑approved medullary thyroid cancer and certain compendial thyroid cancer indications when approval criteria are met; affects providers prescribing this therapy for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCaprelsa (vandetanib) for Thyroid Carcinoma — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization (may be granted for 12 months) and document that the member meets an approved indication and approval criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical authorization duration

FDA‑approved medullaryprimary covered indication

Follicular/Hürthle/papillarycompendial covered types

Coverage Criteria for Caprelsa (vandetanib)

Initial Therapy

Covered when ALL of the following are met:

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCaprelsa (vandetanib) for Thyroid Carcinoma — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization (may be granted for 12 months) and document that the member meets an approved indication and approval criteria.

SourceLink

On This Page

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Indication: Member has one of the covered indications: (1) FDA-approved: symptomatic or progressive medullary thyroid cancer with unresectable locally advanced or metastatic disease; or (2) Compendial: follicular, Hürthle cell, or papillary thyroid carcinoma.

Use in indolent/asymptomatic/slowly progressing medullary disease only after careful consideration of treatment-related risks

Approval criteria: All approval criteria in the policy are met and the member has no exclusions to the prescribed therapy.

Provider Requirements and Authorization Notes

Prior Authorization

Prior authorization: 12-month approvals — Prior authorization may be granted for 12 months for initial or continued treatment when criteria are met.

Prior authorization may be granted for up to 12 months for initial or continued treatment when the member meets the applicable coverage criteria. Authorizations should specify the approved duration (up to 12 months) and be documented in the authorization record.

Authorization duration: up to 12 months
Applies to initial and continuation requests

Denial Risk

Risk consideration for indolent disease — Consider risks before treating indolent, asymptomatic, or slowly progressing medullary thyroid cancer.

Consider the risks of treatment before initiating Caprelsa (vandetanib) in members with indolent, asymptomatic, or slowly progressing medullary thyroid cancer. Treatment-related toxicities may outweigh benefit in these patients; document clinical rationale when electing to treat rather than observe.

Applicable to FDA‑approved indication for symptomatic or progressive medullary thyroid cancer
Weigh risks vs benefit for indolent or asymptomatic disease

Documentation Required

Required indication documentation — Documentation must demonstrate the member meets an approved indication.

Documentation submitted with the authorization request must demonstrate the member meets an approved indication (FDA‑approved medullary thyroid cancer or listed compendial thyroid carcinomas) and any specific criteria required for that indication. Include relevant diagnosis, prior therapies (e.g., RAI eligibility or reason not amenable), imaging or pathology reports, and treatment response or progression history as applicable.

Required: diagnosis and supporting clinical documentation
Include prior treatments and rationale if RAI not amenable
Include evidence of progression or symptoms for medullary thyroid cancer requests

Denial Risk

Non-covered indications risk denial — Use for indications other than FDA-approved medullary or listed compendial thyroid cancers is considered experimental and may be denied.

Use of Caprelsa for indications other than FDA‑approved medullary thyroid cancer or the compendial thyroid carcinoma uses (follicular, Hürthle cell, papillary) is considered experimental/investigational and may be denied. Requests for other diagnoses should include supporting literature; absence of compendial support may result in a denial.

Non‑covered indications: diagnoses not listed as FDA‑approved or compendial (see policy indications)
Experimental/investigational determinations may lead to denial

Definitions and Permitted Uses

FDA-Approved Indication

Indication (FDA)Treatment of symptomatic or progressive medullary thyroid cancer in patients with unresectable locally advanced or metastatic disease.

Use in indolent diseaseUse Caprelsa in indolent, asymptomatic, or slowly progressing medullary thyroid cancer only after careful consideration of treatment‑related risks.

Disease settingUnresectable locally advanced or metastatic medullary thyroid cancer.

Compendial Uses

Compendial tumor typesFollicular, Hürthle cell, and papillary thyroid carcinoma.

RAI-unamenable casesIncludes follicular, Hürthle cell, or papillary thyroid carcinoma that is not amenable to radioactive iodine (RAI) therapy.

Coverage limit for other usesAll other indications beyond the listed compendial uses are considered experimental/investigational and not medically necessary.

OpenPayer

Caprelsa (vandetanib) for Thyroid Carcinoma — Coverage Criteria

Coverage Criteria for Caprelsa (vandetanib)

Provider Requirements and Authorization Notes

Definitions and Permitted Uses

Background