Pharmacy Prior Authorization Criteria

Votrient (pazopanib)

Indications for Prior Authorization

Votrient (pazopanib)

• For diagnosis of Renal Cell Carcinoma (RCC)
  Indicated for the treatment of patients with advanced renal cell carcinoma (RCC).

• For diagnosis of Soft tissue sarcoma (STS)
  Indicated for the treatment of adults with advanced soft tissue sarcoma (STS) who have received prior chemotherapy.

  Limitation of Use: The efficacy of Votrient for the treatment of patients with adipocytic STS or gastrointestinal stromal tumors has not been demonstrated.

Criteria

Brand Votrient, Generic pazopanib*

Prior Authorization (Initial Authorization)

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

• Diagnosis of renal cell carcinoma
AND
• One of the following: [2]
• Disease has relapsed
• Diagnosis of stage IV disease
AND
• Trial or intolerance to generic pazopanib (applies to brand Votrient only)
AND
• One of the following: [2]
• One of the following:
• Both of the following:
• Used in the treatment of non-clear cell renal cell carcinoma
• Trial and failure, contraindication or intolerance to generic sunitinib
OR
• For continuation of prior therapy
OR
• Patient has clear cell renal cell carcinoma

Brand Votrient, Generic pazopanib*

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
AND
• Trial or intolerance to generic pazopanib (applies to brand Votrient only)
AND
• One of the following:
• One of the following:
• Both of the following:
• Used in the treatment of non-clear cell renal cell carcinoma
• Trial and failure, contraindication or intolerance to generic sunitinib
OR
• For continuation of prior therapy
OR
• Patient has clear cell renal cell carcinoma

Brand Votrient, Generic pazopanib*

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Soft tissue sarcoma (STS)

• Diagnosis of advanced soft tissue sarcoma (STS) [4, A]
AND
• Trial or intolerance to generic pazopanib (Applies to Brand Votrient only)

Brand Votrient, Generic pazopanib*

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Soft tissue sarcoma (STS)

• Patient does not show evidence of progressive disease while on therapy
AND
• Trial or intolerance to generic pazopanib (Applies to Brand Votrient only)

P & T Revisions

2026-04-01, 2025-12-09, 2025-03-03, 2024-02-19, 2023-11-23, 2023-06-22, 2023-06-08, 2023-03-21, 2023-03-21, 2022-08-01, 2022-03-02, 2021-09-27, 2021-05-25, 2021-04-13, 2020-03-12

References

1. Votrient Prescribing Information. Novartis Pharmaceuticals. East Hanover, NJ. January 2024.
2. National comprehensive cancer network (NCCN). Clinical practice guidelines in oncology. Kidney cancer v.1.2026. Available at: https://www.nccn.org/professionals/physician_gls/pdf/kidney.pdf. Accessed April 1, 2026.
3. PALETTE: a randomized, double-blind, phase III trial of pazopanib versus placebo in patients (pts) with soft-tissue sarcoma (STS) whose disease has progressed during or following prior chemotherapy-An EORTC STBSG Global Network Study (EORTC 62072). Available at: www.asco.org/ascov2/Meetings/Abstracts?&vmview=abst_detail_view&confID=102&abstractID=83283. Accessed April 30, 2012.
4. National comprehensive cancer network (NCCN). Clinical practice guidelines in oncology. Soft tissue sarcoma v.3.2026. Available at: http://www.nccn.org/professionals/physician_gls/PDF/sarcoma.pdf. Accessed April 1, 2026.

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End Notes

1. Votrient is an active drug in anthracycline pretreated STS patients with an increase in median PFS of 13 weeks. [3]

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Revision History

• 2026-04-01: 2026 Annual Review. Updated trial and failure criteria where applicable to standard verbiage with removal of "and failure". Operational note added. References updated.
• 2025-12-09: Addition of new strength of generic. Added IL statute operational note.
• 2025-03-03: 2025 Annual Review. Background updates only.
• 2024-02-19: 2024 Annual Review
• 2023-11-23: Addition of generic Votrient, PA applied.
• 2023-06-22: Removed Oncology specialist requirement
• 2023-06-08: Update for Soft Tissue Sarcoma to remove criterion that requires "patient received at least one prior chemotherapy."
• 2023-03-21: Annual Review: Updated Soft Tissue Sarcoma criteria to remove listed chemotherapy examples.
• 2023-03-21: COT allowance to support formulary strategy for non-clear cell renal cell carcinoma.
• 2022-08-01: Guideline Update
• 2022-03-02: No criteria changes, updated references.
• 2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
• 2021-04-13: 2021 Annual Review: no changes. Updated GPIs
• 2020-03-12: Annual Review: updated background & references

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