CurrentNeighborhood Health Plan of Rhode IslandPolicy 1783-A

vandetanib (Caprelsa) coverage for thyroid carcinoma

This policy governs coverage and authorization criteria for Caprelsa (vandetanib) for FDA-approved and select compendial thyroid cancer indications for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyvandetanib (Caprelsa) coverage for thyroid carcinoma

Policy CodePolicy 1783-A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionAuthorization of 12 months may be granted for treatment or continued treatment when criteria are met and there is no unacceptable toxicity or disease progression.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization period

1FDA primary indications

3compendial histologies

Coverage Criteria for Vandetanib (Caprelsa)

Initial and continuation therapy criteria

Covered when ALL of the following are met for the specified indication groups

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

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

Compendial differentiated thyroid carcinomas: Member has follicular, oncocytic/Hürthle cell, or papillary thyroid carcinoma that is not amenable to radioactive iodine (RAI) therapy.

Compendial uses accepted as covered when criteria are met.

Authorization duration: Authorization of 12 months may be granted for treatment of thyroid carcinoma when criteria are met.12 months

Continuation of therapy: authorization of 12 months may be granted when there is no unacceptable toxicity or disease progression.

Authorization, Prescribing, and Provider Guidance

Prior Authorization

Prior Authorization Duration

Authorization of 12 months may be granted for treatment of thyroid carcinoma when criteria are met. Authorization of 12 months may also be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Authorization duration: 12 months for initial treatment when coverage criteria are met
Continuation: 12 months if no unacceptable toxicity or disease progression

Denial Risk

Risk consideration before treating indolent disease

Use in indolent, asymptomatic, or slowly progressing medullary thyroid cancer only after careful consideration of the risks and benefits of treatment with Caprelsa (vandetanib). Discuss alternative management and document rationale when treating patients with minimally symptomatic or indolent disease.

Documentation Required

References for Prescribing

Prescribing should reference the FDA-approved product labeling and the NCCN Drugs & Biologics Compendium for dosing, monitoring, and safety information.

Primary references: Caprelsa (vandetanib) package insert
Compendial guidance: NCCN Drugs & Biologics Compendium

Denial Risk

Non-covered indications

All other indications not listed in the coverage criteria are considered experimental/investigational and not medically necessary.

Background and Definitions

Vandetanib (Caprelsa) is an oral targeted therapy recognized for use in thyroid carcinoma settings. The policy acknowledges the drug’s role in the FDA-approved setting of medullary thyroid cancer and also recognizes select compendial differentiated thyroid carcinoma histologies (follicular, oncocytic/Hürthle cell, and papillary) when criteria are met. Treatments outside these indicated or compendial contexts are considered experimental and not medically necessary.

FDA‑approved indication

FDA-approved indicationTreatment of symptomatic or progressive medullary thyroid cancer in patients with unresectable locally advanced or metastatic disease.

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

Authorization noteAuthorization of 12 months may be granted for treatment when criteria are met; continuation requires absence of unacceptable toxicity or disease progression.

Compendial uses

Compendial histologies acceptedFollicular, oncocytic/Hürthle cell, and papillary thyroid carcinoma.

Coverage conditionCoverage contingent on member having disease not amenable to radioactive iodine (RAI) therapy when specified.

Non‑covered usesAll other indications are considered experimental/investigational and not medically necessary.