Cabometyx

Drug - Cabometyx® (cabozantinib) [Exelixis,Inc.]

January 2018

Therapeutic area - Oncology

Initial approval criteria

• Patient is 18 years of age or older AND
• Must have a diagnosis of advanced renal cell carcinoma (RCC) AND
• Must have received prior anti-angiogenic therapy AND
• Must not have recent history of hemorrhage not due to trauma AND
• Must be used as monotherapy AND
• Documentation of diagnosis from patient’s medical records must be provided at time of request

Renewal criteria

• Documentation must be supplied at time of request showing patient has no disease progression AND
• Must not have any one of the following:
  • Hemorrhage not due to trauma
  • Unmanaged gastrointestinal perforations or fistulas
  • Palmar-plantar erythrodysesthesia syndrome Grade 2 or 3
  • Uncontrolled severe hypertension

Approvals

Initial and renewal approval will be for 6 months

Quantity limits

34 tablets per 34 days

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411