CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Caprelsa (vandetanib) — Coverage Criteria for Thyroid Carcinoma

Covers indications, authorization durations, and continuation criteria for Caprelsa (vandetanib) for members of Neighborhood Health Plan of Rhode Island when used for FDA‑approved and certain compendial thyroid cancer indications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCaprelsa (vandetanib) — Coverage Criteria for Thyroid Carcinoma

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document specific thyroid cancer diagnosis, disease status, and treatment risk considerations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

medullaryFDA‑approved covered indication

follicular, Hürthle, papillarycompendial covered types

other indicationsnot medically necessary

Coverage Criteria for Caprelsa (vandetanib)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered Indication: Member has symptomatic or progressive medullary thyroid cancer that is unresectable locally advanced or metastatic OR member has follicular, oncocytic/Hürthle cell, or papillary thyroid carcinoma (compendial use)

Compendial uses limited to listed histologies

Disease status for compendial histologies: For follicular, oncocytic/Hürthle cell or papillary carcinoma: disease is not amenable to radioactive iodine (RAI) therapy

One of these conditions supports authorization for compendial uses

Risk consideration for indolent disease: If disease is indolent, asymptomatic, or slowly progressing, treatment with Caprelsa should be considered only after careful consideration of treatment-related risks

Applies particularly to medullary thyroid cancer per FDA guidance

Continuation Therapy

Covered for continuation when ALL of the following are met:

Continuation: There is no evidence of unacceptable toxicity or disease progression while on the current regimen

Authorization of 12 months may be granted for continued treatment

Provider Actions and Authorization Details

Prior Authorization

Authorization duration and renewals

Prior authorization may be granted for 12 months for treatment of thyroid carcinoma when criteria are met; continuation authorizations of 12 months may be granted if there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Step Therapy

Step therapy not required

No step therapy requirements are specified in this policy for Caprelsa (vandetanib).

Documentation Required

Required clinical documentation

Provider must document the specific thyroid cancer diagnosis, disease status, and consideration of treatment risks for indolent disease.

Specific histologic diagnosis (medullary; follicular, oncocytic/Hürthle cell; or papillary thyroid carcinoma).
Disease status: unresectable locally advanced or metastatic for medullary thyroid cancer; for follicular/oncocytic/Hürthle cell or papillary carcinoma, documentation that disease is not amenable to radioactive iodine (RAI) therapy.
Evidence that treatment risks were considered for indolent, asymptomatic, or slowly progressing disease.

Denial Risk

Noncovered indications — denial risk

Use of Caprelsa for indications other than FDA‑approved medullary thyroid cancer or the listed compendial histologies (follicular, oncocytic/Hürthle cell, papillary) is considered experimental/investigational and may be denied as not medically necessary.

Background

Vandetanib (Caprelsa) is recognized in this policy for its role in thyroid carcinoma management per the listed indications. The policy specifically includes the FDA‑approved use for medullary thyroid cancer and also lists certain compendial uses — follicular, oncocytic/Hürthle cell, and papillary thyroid carcinoma — while excluding other, nonlisted indications as experimental/investigational.

Definitions

inv-10: Definition — unresectable locally advanced or metastatic medullary thyroid cancer

Short definitionMedullary thyroid cancer that cannot be completely removed surgically or has spread beyond the thyroid (unresectable locally advanced or metastatic)

FDA‑approved useTreatment of symptomatic or progressive disease in patients with unresectable locally advanced or metastatic medullary thyroid cancer

Risk noteUse in indolent, asymptomatic, or slowly progressing disease should follow careful consideration of Caprelsa's treatment‑related risks

inv-11: Definition — not amenable to radioactive iodine (RAI) therapy

Short definitionDisease or tumor for which radioactive iodine (RAI) therapy is not effective or feasible (not amenable to RAI)

Authorized compendial histologiesSupports authorization for follicular, oncocytic/Hürthle cell, or papillary thyroid carcinoma when not amenable to RAI

Policy implicationOne of the named conditions (not amenable to RAI) qualifies the member for a 12‑month authorization for thyroid carcinoma treatment