Subject: Inlyta 2079-A SGM P2024
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 Indications
1. First-Line Advanced Renal Cell Carcinoma
a. Inlyta in combination with avelumab is indicated for the first-line treatment of patients
with advanced renal cell carcinoma (RCC).
b. Inlyta in combination with pembrolizumab is indicated for the first-line treatment of
patients with advanced renal cell carcinoma.
2. Second-Line Advanced Renal Cell Carcinoma
Inlyta as a single agent is indicated for the treatment of advanced renal cell carcinoma
(RCC) after failure of one prior systemic therapy.
B. Compendial Uses
1. Relapsed or stage IV renal cell carcinoma
2. Papillary, Oncocytic (Hürthle cell) or Follicular thyroid carcinoma
3. Soft tissue sarcomas: alveolar soft part sarcoma (ASPS)
All other indications are considered experimental/investigational and not medically necessary.
II. PRESCRIBER SPECIALTIES
This medication must be prescribed by or in consultation with an oncologist.
III. CRITERIA FOR INITIAL APPROVAL
A. Renal Cell Carcinoma
Authorization of 12 months may be granted for treatment of advanced, relapsed, or stage IV
renal cell carcinoma when any of the following criteria is met:
1. Inlyta will be used as a single agent
2. Inlyta will be used in combination with pembrolizumab
3. Inlyta will be used as first-line treatment in combination with avelumab
B. Papillary, Oncocytic (Hürthle cell), or Follicular Thyroid Carcinoma
Authorization of 12 months may be granted for treatment of progressive and/or symptomatic
papillary, Oncocytic (Hürthle cell), or follicular thyroid carcinoma that is not amenable to
radioactive iodine (RAI) therapy.
C. Soft Tissue Sarcomas
Authorization of 12 months may be granted for treatment of alveolar soft part sarcoma
(ASPS) subtype of soft tissue sarcoma when used in combination with pembrolizumab.
IV. CONTINUATION OF THERAPY
Authorization of 12 months may be granted for continued treatment in members requesting
reauthorization for an indication listed in Section III 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:
- Inlyta [package insert]. New York, NY: Pfizer Inc., September 2022.
- The NCCN Drugs & Biologics Compendium® © 2024 National Comprehensive Cancer Network, Inc. http://www.nccn.org. Accessed May 7, 2024.
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.
November 03, 2024
