Pharmacy Prior Authorization Criteria

Fotivda (tivozanib) - PA, NF

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.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Renal Cell Carcinoma (RCC)

AND

AND

Patient has received two or more prior systemic therapies (e.g., chemotherapy)

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Renal Cell Carcinoma (RCC)

Non Formulary

Length of Approval: 12 Month(s)
For diagnosis of Renal Cell Carcinoma (RCC)

Submission of medical records (e.g., chart notes) confirming both of the following:

AND

AND

Submission of medical records (e.g., chart notes) or paid claims confirming patient has received two or more prior systemic therapies (e.g., chemotherapy)

2026-03-30, 2025-05-09, 2024-05-21, 2023-06-26, 2023-05-03, 2022-04-07, 2022-01-04, 2021-06-16

Fotivda Prescribing Information. AVEO Pharmaceuticals, Inc. Boston, MA. January 2025.

2026-03-30: Annual Review 2026 - Update NF criteria for standard NF verbiage. Background updates
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.