CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cabometyx (cabozantinib) coverage

Policy governing prior authorization and coverage criteria for cabozantinib (Cabometyx) for FDA-approved and selected compendial oncology indications for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCabometyx (cabozantinib) coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required; authorization of up to 12 months may be granted for covered indications when all criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical authorization duration

FDA & compendiaindications covered when criteria met

RET+ NSCLCRET documentation required

Failed ≥4GIST prior therapy

Coverage Criteria for Cabometyx (cabozantinib)

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Hepatocellular Carcinoma (HCC)

Covered when ALL of the following are met for hepatocellular carcinoma (HCC):

HCC subsequent therapy: Cabometyx used as single agent for hepatocellular carcinoma in members previously treated with sorafenib

Authorization of 12 months may be granted

Differentiated Thyroid Cancer (DTC)

Covered when ALL of the following are met for differentiated thyroid cancer (DTC):

DTC after VEGFR therapy: Locally advanced or metastatic differentiated thyroid cancer that has progressed following prior VEGFR-targeted therapy and who are radioactive iodine-refractory or ineligible; member at least 12 years old

Authorization of 12 months may be granted

Non-Small Cell Lung Cancer (RET rearrangement)

Covered when ALL of the following are met for non-small cell lung cancer (NSCLC) with RET rearrangement:

RET+ NSCLC: Recurrent, advanced, or metastatic non-small cell lung cancer with documented RET gene rearrangement

Submission of documentation confirming RET gene rearrangement is required; authorization of 12 months may be granted

Ewing Sarcoma and Osteosarcoma

Covered when ALL of the following are met for sarcomas:

Ewing sarcoma: Treatment of Ewing sarcoma as a single agent for subsequent therapy

Authorization of 12 months may be granted

Osteosarcoma: Treatment of osteosarcoma as a single agent for subsequent therapy

Authorization of 12 months may be granted

Gastrointestinal Stromal Tumor (GIST)

Covered when ALL of the following are met for GIST:

GIST subsequent therapy: Member has residual, unresectable, recurrent, or metastatic disease; member has failed at least four FDA-approved therapies (e.g., imatinib, sunitinib, regorafenib, ripretinib); requested medication will be used as a single agent

Authorization of 12 months may be granted

Endometrial Carcinoma

Covered when ALL of the following are met for endometrial carcinoma:

Endometrial carcinoma subsequent therapy: Treatment of recurrent endometrial carcinoma as a single agent for subsequent therapy

Authorization of 12 months may be granted

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Authorization of up to 12 months may be granted for covered indications when all criteria are met.

Authorization length: up to 12 months for covered indications when criteria are met
Prior authorization required to initiate review

Step Therapy

GIST prior therapy requirement

For Gastrointestinal Stromal Tumor (GIST), the member must have residual, unresectable, recurrent, or metastatic disease (including tumor rupture), and documentation must show the member has failed at least four FDA‑approved therapies before cabozantinib will be approved.

Required prior therapies (examples): imatinib, sunitinib, regorafenib, ripretinib
Requested medication must be used as a single agent

Documentation Required

Molecular testing documentation

Submission of documentation confirming RET gene rearrangement is required to initiate prior authorization review for non‑small cell lung cancer.

Provide molecular testing report demonstrating RET rearrangement

Denial Risk

Experimental/Investigational exclusions

Use of cabozantinib for indications not listed as covered (Section IIl/Compendial Uses) is considered experimental and investigational and is not medically necessary; such requests may be denied.

All other indications are considered experimental/investigational and not medically necessary

Reauthorization / Continuation Requirements

Continuation/Reauthorization

Reauthorization requirements:

Continuation of therapy: Authorization of 12 months may be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen

Step Therapy and Prior Treatment Documentation

Prior therapy documented	Details required
Failed >= 4 FDA‑approved therapies
List each prior FDA‑approved agent (examples: imatinib, sunitinib, regorafenib, ripretinib) and dates of therapy
Disease status confirming indication: residual, unresectable, recurrent, or metastatic GIST
Planned use as single agent (confirmation that cabozantinib will be used alone)

Background

Cabozantinib (Cabometyx) is an oral multi‑kinase (tyrosine kinase) inhibitor with oncology indications described in the policy, including FDA‑approved and compendial uses such as advanced renal cell carcinoma, hepatocellular carcinoma, differentiated thyroid cancer, RET‑rearranged non‑small cell lung cancer, selected sarcomas, gastrointestinal stromal tumor, and endometrial carcinoma.

Definitions

RET+ (RET gene rearrangement)

DefinitionRET+ indicates presence of a RET (rearranged during transfection) gene rearrangement

Clinical relevanceRET rearrangements identify non-small cell lung cancers and other tumors that may be eligible for targeted therapy

Documentation requirementSubmission of documentation confirming RET gene rearrangement is required to initiate prior authorization for RET+ NSCLC

Source classificationListed as a compendial use in the policy (Non-small cell lung cancer with RET gene rearrangement)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCabometyx (cabozantinib) coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required; authorization of up to 12 months may be granted for covered indications when all criteria are met.

SourceLink

On This Page

OpenPayer

Cabometyx (cabozantinib) coverage

Coverage Criteria for Cabometyx (cabozantinib)

Provider Requirements and Authorization

Initial Authorization Criteria

Reauthorization / Continuation Requirements

Step Therapy and Prior Treatment Documentation

Background

Definitions