Pazopanib Tablets (Votrient®) Prior Authorization Criteria

Pazopanib Tablets (Votrient®) Prior Authorization Request Form

Covered Uses

Renal cell carcinoma (RCC)

Exclusion Criteria

None

Required Medical Information

Document one of the following:

• Disease relapse
• Stage IV and medically or surgically unresectable disease,
• Progression despite cytokine therapy

Age Restrictions

None

Prescriber Restrictions

• Oncologist
• Hematologist

Coverage Duration

Every prescription is authorized for up to six (6) months depending on refills written in prescription

Other Criteria

None