Prior Authorization: Thyroid Carcinoma:
Thyroid Carcinoma 1. Initial Authorization a. Caprelsa will be approved based on all of the following criteria: (a) One of the following diagnosis: i. Follicular Carcinoma ii. Hurthle Cell Carcinoma iii. Papillary Carcinoma -AND- (b) One of the following: i. Unresectable recurrent ii. Persistent locoregional disease iii. Metastatic disease -AND- (c) One of the following: i. Patient has symptomatic disease ii. Patient has progressive disease -AND- (d) Disease is refractory to radioactive iodine treatment Authorization will be issued for 12 months. 2. Reauthorization a. Caprelsa will be approved based on the following criterion: (1) Patient does not show evidence of progressive disease while on Caprelsa therapy Authorization will be issued for 12 months.