CurrentNeighborhood Health Plan of Rhode IslandPolicy 1809-A

Regorafenib (Stivarga) — Coverage Criteria

Defines medical necessity criteria and authorization guidance for regorafenib (Stivarga) for FDA‑approved and select compendial oncology indications for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRegorafenib (Stivarga) — Coverage Criteria

Policy CodePolicy 1809-A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization; approval is typically granted for 12 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical authorization period

3FDA indications

multiplecompendial uses

Coverage Criteria for Regorafenib (Stivarga)

Colorectal Cancer (CRC) — Initial therapy

Covered when ALL of the following are met for metastatic colorectal cancer (CRC):

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CRC initial coverage: Member has metastatic colorectal cancer (including appendiceal or anal adenocarcinoma) and has progressed on fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy (with or without bevacizumab); and if tumor is RAS wild-type, member has received an anti-EGFR therapy for left-sided colon, rectal, appendiceal, or anal adenocarcinoma.

Authorization of 12 months may be granted; exceptions for contraindication or intolerance permitted.

Gastrointestinal Stromal Tumor (GIST)

Covered when ANY of the following are met for GIST:

GIST criterion A: Requested medication will be used as a single agent for locally advanced, residual, unresectable, tumor rupture, or recurrent/metastatic GIST following disease progression on imatinib and either sunitinib or ripretinib.