Subject: Odomzo 1786-A SGM P2023

Drug

ODOMZO  (sonidegib)

Policy:

      I.  INDICATIONS
          The indications below including FDA-approved indications and
          compendial uses are considered a covered benefit provided that
          all the approval criteria are met and the member has no
          exclusions to the prescribed therapy.

          A.  FDA-Approved Indication
               Odomzo is indicated for the treatment of adult patients with
               locally advanced basal cell carcinoma (BCC) that has
               recurred following surgery or radiation therapy, or those who
               are not candidates for surgery or radiation therapy.

          B.  Compendial Use
               Basal cell carcinoma

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

 
    II.  CRITERIA FOR INITIAL APPROVAL

          Basal Cell Carcinoma
          Authorization of 12 months may be granted for treatment of
          locally advanced or diffuse (e.g., Gorlin syndrome) basal cell
          carcinoma.

  III.  CONTINUATION OF THERAPY

          Authorization of 12 months may be granted for continued
          treatment in members requesting reauthorization for an
          indication listed in Section II when there is no evidence of
          unacceptable toxicity or disease progression while on the current
          regimen.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Odomzo [package insert]. Cranberry, NJ: Sun Pharmaceutical Industries, Inc.; May 2019.
2. The NCCN Drugs & Biologics Compendium^® © 2022 National Comprehensive Cancer Network Drugs, Inc. Available at https://www.nccn.org. Accessed November 7, 2022.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

April 15, 2023