Fotivda (tivozanib) - PA, NF
Indications for Prior Authorization
Fotivda (tivozanib)
-
For diagnosis of Renal cell carcinoma (RCC)
Indicated for the treatment of adult patients with relapsed or refractory advanced renal cell carcinoma (RCC) following two or more prior systemic therapies.
Criteria
Fotivda
Prior Authorization (Initial Authorization)
Length of Approval: 12 Month(s)
For diagnosis of Renal cell carcinoma (RCC)
- Diagnosis of advanced renal cell carcinoma (RCC) AND
- Disease is one of the following:
- Relapsed
- Refractory
- Patient has received two or more prior systemic therapies (e.g., chemotherapy)
Fotivda
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
For diagnosis of Renal cell carcinoma (RCC)
- Patient does not show evidence of progressive disease while on therapy
Fotivda
Non Formulary
Length of Approval: 12 Month(s)
For diagnosis of Renal cell carcinoma (RCC)
- Diagnosis of advanced renal cell carcinoma (RCC) AND
- Disease is one of the following:
- Relapsed
- Refractory
- Patient has received two or more prior systemic therapies (e.g., chemotherapy)
P & T Revisions
2025-05-09, 2024-05-21, 2023-06-26, 2023-05-03, 2022-04-07, 2022-01-04, 2021-06-16
References
- Fotivda Prescribing Information. AVEO Pharmaceuticals, Inc. Boston, MA. February 2025.
- The NCCN Drugs and Biologics Compendium (NCCN Compendium™). Available at https://www.nccn.org/professionals/drug_compendium/content/. Accessed May 8, 2025
Revision History
- 2025-05-09: 2025 Annual Review. Background updates only.
- 2024-05-21: 2024 annual review: Updated diagnosis to say "diagnosis of advanced renal cell carcinoma" to align with FDA-approved label.
- 2023-06-26: Removed specialist requirement.
- 2023-05-03: Annual review: Replaced examples of systemic therapy with "chemotherapy." Updated references.
- 2022-04-07: Annual review: No criteria changes, updated references.
- 2022-01-04: Added specific NF sections that mirror initial PA since its excluded on Premium
- 2021-06-16: New program.
HEALTHY LIVING