CurrentUnitedHealthcarePolicy N/A

Votrient (pazopanib) prior authorization criteria

Prior authorization and notification criteria for coverage of Votrient (pazopanib) for UnitedHealthcare members, including indications, initial and reauthorization rules, and pediatric automatic processing. Applies to pharmacy benefit coverage determinations.

Policy Summary

PayerUnitedHealthcare

PolicyVotrient (pazopanib) prior authorization criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2026

Next Review DateNov 1, 2025

Key ActionObtain prior authorization for members age 19 and older and document diagnosis, disease status, and prior therapies as required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical authorization duration

age <19pediatric auto-processing

multiplecovered tumor types

no progressionreauthorization condition

NCCN-supportedNCCN recognition

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.

Coverage Criteria

Initial Authorization - Renal Cell Carcinoma

Covered when ONE of the following is met for RCC:

RCC criteria set: (1) Both of the following: (a) Diagnosis of renal cell carcinoma (RCC) AND (b) one of: disease has relapsed; stage IV disease; disease is advanced

VHL-associated RCC: (2) Diagnosis of von Hippel-Lindau (VHL)-associated renal cell carcinoma

Initial Authorization - Soft Tissue Sarcomas

Covered when ALL of the following are met:

Diagnosis in listed sarcoma types: Diagnosis of one of the following soft tissue sarcoma histologies: alveolar soft part sarcoma; angiosarcoma; dedifferentiated chordoma; dedifferentiated liposarcoma (with or without concurrent well-differentiated liposarcoma); Dermatofibrosarcoma protuberans (DFSP) with fibrosarcomatous transformation; desmoid tumors (aggressive fibromatosis); epithelioid hemangioendothelioma; extraskeletal myxoid chondrosarcoma; soft tissue sarcoma of the extremity/superficial trunk/head/neck with stage IV or recurrent disease and disseminated metastases; retroperitoneal/intra-abdominal unresectable or stage IV or postoperative residual disease; pleomorphic rhabdomyosarcoma; solitary fibrous tumor/hemangiopericytoma

Authorization issued for 12 months

Initial Authorization - Thyroid Carcinoma

Covered when ONE of the following thyroid-specific criterion sets is met:

Follicular or Papillary carcinoma: (a) Diagnosis of follicular or papillary carcinoma AND (b) one of: unresectable locoregional recurrent disease; persistent disease; metastatic disease AND (c) one of: patient has symptomatic disease; patient has progressive disease AND (d) one of: disease is refractory to radioactive iodine treatment; distant metastatic disease not amenable to radioactive iodine treatment

Oncocytic carcinoma: (a) Diagnosis of oncocytic carcinoma AND (b) one of: unresectable locoregional recurrent disease; persistent disease; metastatic disease AND (c) one of: patient has symptomatic disease; patient has progressive disease

Medullary carcinoma: (a) Diagnosis of medullary carcinoma AND (b) one of: disease is progressive; disease is symptomatic with distant metastases AND (c) history of failure, contraindication, or intolerance to vandetanib or cabozantinib (Cometriq)

Authorization issued for 12 months

Initial Authorization - Uterine Sarcoma

Covered when ALL of the following are met:

Uterine sarcoma: (1) Diagnosis of uterine sarcoma AND (2) one of: disease is advanced; disease is recurrent/metastatic; disease is inoperable

Initial Authorization - Ovarian/Peritoneal

Covered when ALL of the following are met:

Ovarian/fallopian tube/primary peritoneal: (1) Diagnosis of epithelial ovarian cancer, fallopian tube cancer, or primary peritoneal cancer AND (2) one of: disease is persistent; disease is recurrent

Authorization issued for 12 months

Initial Authorization — Ovarian/fallopian/primary peritoneal cancers

Covered when ALL of the following are met

Ovarian region cancers: (1) Diagnosis of epithelial ovarian cancer OR fallopian tube cancer OR primary peritoneal cancer

Disease status: (2) Disease is persistent OR recurrent

Initial Authorization — Chondrosarcoma

Covered when ALL of the following are met

Chondrosarcoma criteria: (1) Diagnosis of chondrosarcoma AND (2) disease is metastatic and widespread

Authorization will be issued for 12 months

Initial Authorization — GIST

Covered when ALL of the following are met

GIST diagnosis and disease status: (1) Diagnosis of GIST AND (2) disease is residual, unresectable, progressive, or metastatic

GIST line/previous therapy: (3) Either used as first-line therapy in SDH-deficient GIST OR used after progression on all of: imatinib; sunitinib; regorafenib (Stivarga); standard dose ripretinib (Qinlock)

Authorization will be issued for 12 months

Initial Authorization — Merkel Cell Carcinoma

Covered when ALL of the following are met

Merkel Cell Carcinoma: (1) Diagnosis of Merkel cell carcinoma AND (2) one of: anti-PD-L1 or anti-PD-1 therapy is contraindicated; disease has progressed on anti-PD-L1 or anti-PD-1 therapy

Text in source is partial

For members under the age of 19 years, prescriptions for Votrient (pazopanib) will automatically process without a coverage review. This portion of the policy does not list any pediatric exclusions; coverage criteria and clinical review requirements described elsewhere in the policy apply to members age 19 and older.

Coverage may be affected by state mandates that require coverage or recognition of alternate compendia for certain off‑label uses; where state mandates apply, they supersede the benefit document or notification criteria. In addition, member‑specific benefit plan terms and other UnitedHealthcare utilization programs may apply. UnitedHealthcare may approve initial and reauthorization requests based on previous claim/medication history, diagnosis codes (ICD‑10), and/or automated claim logic, and a supply limit may be in place.

Initial Therapy Criteria

Initial authorization criteria vary by diagnosis and typically require specific diagnosis and disease status.

RCC or VHL: Initial approval for RCC requires diagnosis of RCC with relapse, stage IV, or advanced disease; VHL-associated RCC is separately listed

Sarcoma histologies: Initial approval for listed sarcoma histologies when disease is advanced/unresectable or metastatic as specified

Authorization issued for 12 months for many sarcoma histologies

Thyroid types: Initial approval for follicular, papillary, oncocytic, or medullary thyroid carcinoma with additional locoregional/metastatic/symptomatic/progressive or refractory-to-radioactive-iodine requirements; medullary requires prior vandetanib or cabozantinib failure/intolerance/contraindication

Uterine and ovarian-related: Initial approval for uterine sarcoma when advanced/recurrent/metastatic/inoperable; for epithelial ovarian/fallopian tube/primary peritoneal cancer when persistent or recurrent

Initial therapy authorization duration

Initial authorization will be issued for 12 months when indication-specific criteria are met.

See indication-specific nodes: Refer to coverage criteria sets for initial authorization details

Authorization will be issued for 12 months

Initial Therapy Criteria (by diagnosis)

Reauthorization

Reauthorization is approved when the following is met:

No progression: Patient does not show evidence of progressive disease while on Votrient therapy

Applies across multiple indications per document (RCC, sarcoma, thyroid, uterine, ovarian, chondrosarcoma, GIST, Merkel cell)

Initial Authorization - Soft Tissue Sarcomas

Covered when ALL of the following are met:

Diagnosis in listed sarcoma types: Diagnosis of one of the following soft tissue sarcoma histologies: alveolar soft part sarcoma; angiosarcoma; dedifferentiated chordoma; dedifferentiated liposarcoma (with or without concurrent well-differentiated liposarcoma); Dermatofibrosarcoma protuberans (DFSP) with fibrosarcomatous transformation; desmoid tumors (aggressive fibromatosis); epithelioid hemangioendothelioma; extraskeletal myxoid chondrosarcoma; soft tissue sarcoma of the extremity/superficial trunk/head/neck with disease that is stage IV or recurrent and has disseminated metastases; retroperitoneal/intra-abdominal unresectable or stage IV or postoperative treatment for residual disease; pleomorphic rhabdomyosarcoma; solitary fibrous tumor/hemangiopericytoma

Authorization issued for 12 months

Initial Authorization - Thyroid Carcinoma

Covered when ONE of the following thyroid-specific criterion sets is met:

Authorization issued for 12 months

Initial Authorization - Uterine Sarcoma

Covered when ALL of the following are met:

Uterine sarcoma: (1) Diagnosis of uterine sarcoma AND (2) one of: disease is advanced; disease is recurrent/metastatic; disease is inoperable

Initial Authorization - Ovarian/Peritoneal

Covered when ALL of the following are met:

Ovarian/fallopian tube/primary peritoneal: (1) Diagnosis of epithelial ovarian cancer, fallopian tube cancer, or primary peritoneal cancer AND (2) one of: disease is persistent; disease is recurrent

Authorization issued for 12 months

Initial Authorization — Chondrosarcoma

Covered when ALL of the following are met

Chondrosarcoma criteria: (1) Diagnosis of chondrosarcoma AND (2) disease is metastatic and widespread

Authorization will be issued for 12 months

Initial Authorization — GIST

Covered when ALL of the following are met

GIST diagnosis and disease status: (1) Diagnosis of GIST AND (2) disease is residual, unresectable, progressive, or metastatic

Authorization will be issued for 12 months

Initial Authorization — Merkel Cell Carcinoma

Covered when ALL of the following are met

Merkel Cell Carcinoma: (1) Diagnosis of Merkel cell carcinoma AND (2) one of: anti-PD-L1 or anti-PD-1 therapy is contraindicated; disease has progressed on anti-PD-L1 or anti-PD-1 therapy

Text in source is partial

Initial therapy authorization duration

Initial authorization will be issued for 12 months when indication-specific criteria are met.

See indication-specific nodes: Refer to coverage criteria sets for initial authorization details

Authorization will be issued for 12 months

Continuation / Reauthorization Criteria

Reauthorization

Reauthorization — Reauthorization is approved when the following is met

ALL of the following

Patient does not show evidence of progressive disease while on Votrient therapy
Authorization will be issued for 12 months.

Continuation Therapy

Continuation Therapy — Reauthorization/continuation is allowed when patient shows no evidence of progressive disease while on therapy.

ALL of the following

Patient does not show evidence of progressive disease while on Votrient therapy
Authorization will be issued for 12 months.

Reauthorization Rules

Continuation/Reauthorization — Reauthorization rules

ALL of the following

Patient does not show evidence of progressive disease while on Votrient therapy
Authorization will be issued for 12 months.

Denial Risk

Reauthorization Denial Risk

Reauthorization may be denied if the patient shows evidence of progressive disease while on Votrient therapy. Ensure documentation demonstrates stability or response to therapy at time of reauthorization request.

Evidence of progressive disease on Votrient is a denial risk
Provide clinical documentation of disease status to support continuation

Provider Actions and Requirements

Prior Authorization

Prior authorization required for members ≥19

Prior authorization is required per UnitedHealthcare Pharmacy Clinical Pharmacy Programs for Votrient (pazopanib) for members age 19 and older; the program header lists the program number and that this is a Prior Authorization/Notification program.

Prior Authorization

Indication-specific prior authorization and approval

Prior authorization is required and will be approved when indication-specific diagnostic and disease-state criteria are met (examples include persistent or recurrent epithelial ovarian/fallopian/primary peritoneal cancers; metastatic widespread chondrosarcoma; GIST that is residual/unresectable/progressive/metastatic with SDH‑deficient first‑line use or after progression on specified TKIs).

Step Therapy

Medullary thyroid carcinoma — prior therapy required

For medullary thyroid carcinoma, prior authorization requires a history of failure, contraindication, or intolerance to vandetanib or cabozantinib (Cometriq) before Votrient will be approved.

Step Therapy

GIST — prior progression or SDH‑deficient first‑line exception

For GIST, authorization requires diagnosis of GIST with residual, unresectable, progressive, or metastatic disease and either use as first‑line therapy for SDH‑deficient GIST or prior progression on imatinib, sunitinib, regorafenib (Stivarga), and standard‑dose ripretinib (Qinlock).

Documentation Required

Pediatric auto‑process; documentation for adults

Prescriptions for members under age 19 will automatically process without a coverage review; for members age 19 and older, provide documentation supporting diagnosis, disease stage/status, prior therapies (when required), and evidence of no progression for reauthorization.

Billing Rule

Automated approval and possible supply limits

UnitedHealthcare may approve initial and reauthorization requests based solely on previous claim/medication history, diagnosis codes (ICD‑10), and/or claim logic; a supply limit may apply.

Note

Coverage review required for members ≥19

Coverage review is required for members age 19 and older; failure to meet the listed clinical criteria for the requested indication may result in denial.

Denial Risk

Reauthorization denial trigger — progression

Reauthorization may be denied if the patient shows evidence of progressive disease while on Votrient therapy.

OpenPayer

Votrient (pazopanib) prior authorization criteria

Coverage Criteria

Initial Therapy Criteria (by diagnosis)

Continuation / Reauthorization Criteria

Provider Actions and Requirements

Step Therapy Requirements

Quantity Limits

Background

Definitions

Provider Notes & Special Processing

Step	Requirement
1
History of failure, contraindication, or intolerance to vandetanib or cabozantinib (Cometriq)

Step	Requirement
1
Patient must have progressed on imatinib, sunitinib, regorafenib (Stivarga), and standard dose ripretinib (Qinlock), unless Votrient is used as first-line therapy for SDH-deficient GIST