CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Caprelsa (vandetanib) coverage

Policy governing coverage and authorization criteria for Caprelsa (vandetanib) for treatment of thyroid cancers for members of Neighborhood Health Plan of Rhode Island. Applies to clinicians requesting benefit coverage and prior authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCaprelsa (vandetanib) coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required and may be granted for 12 months when coverage criteria are met; documentation must support the FDA‑approved indication or specified compendial use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration when granted

FDA-approvedindication status

Not medically necessaryother indications

Coverage Criteria for Caprelsa (vandetanib)

Covered indications and continuation

Covered when ALL of the following are met:

FDA-approved indication: Patient has symptomatic or progressive medullary thyroid cancer that is unresectable locally advanced or metastatic.

Use in indolent, asymptomatic, or slowly progressing disease only after careful consideration of treatment-related risks.

Compendial/other thyroid carcinoma: Authorization of 12 months may be granted for treatment of follicular, Hurthle cell, or papillary thyroid carcinoma that is not amenable to radioactive iodine (RAI) therapy, or for medullary thyroid carcinoma when criteria are met.

See authorization duration and continuation criteria.

Continuation: No evidence of unacceptable toxicity or disease progression while on the current regimen for continued treatment.

Authorization of 12 months may be granted for continuation if no unacceptable toxicity or disease progression.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCaprelsa (vandetanib) coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required and may be granted for 12 months when coverage criteria are met; documentation must support the FDA‑approved indication or specified compendial use.

SourceLink

On This Page

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Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Authorization of up to 12 months may be granted when criteria are met for initial treatment or for continuation of therapy.

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

Denial Risk

Risk Consideration Before Use

Use Caprelsa (vandetanib) in patients with indolent, asymptomatic, or slowly progressing disease only after careful consideration of treatment‑related risks.

Documentation Required

Required Clinical Documentation

Documentation must support the FDA‑approved indication: treatment of symptomatic or progressive medullary thyroid cancer that is unresectable locally advanced or metastatic. For other thyroid carcinoma indications considered for authorization, clinical records must justify inability to use radioactive iodine therapy or meet other listed criteria. Include prior treatment history, diagnostic imaging, pathology reports, and evidence of disease progression or symptoms where applicable.

Required documentation: diagnosis and staging, pathology or molecular testing, radiology reports, prior therapies and outcomes, documentation of symptoms or progression

Denial Risk

Non‑covered Indications

Use for indications other than the FDA‑approved indication or listed compendial uses is considered experimental/investigational and not medically necessary.

Definitions

Definition — Symptomatic or progressive medullary thyroid cancer (unresectable locally advanced or metastatic)

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

Use in indolent/asymptomatic diseaseUse Caprelsa in patients with indolent, asymptomatic, or slowly progressing disease only after careful consideration of treatment-related risks.

Disease extent specifiedApplies when disease is unresectable locally advanced or metastatic.

Symptom/progression requirementPatient’s medullary thyroid cancer must be symptomatic or demonstrate progression to meet the FDA-approved indication.

OpenPayer

Caprelsa (vandetanib) coverage

Coverage Criteria for Caprelsa (vandetanib)

Provider Actions and Authorization Requirements

Background

Definitions