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VANDETANIB (CAPRELSA) –ORAL CHEMOTHERAPY

A.  Vandetanib is considered medically indicated in the treatment of metastatic or unresectable locally advanced medullary thyroid cancer (symptomatic or progressive)..
B.    The decision to treat a patient with vandetanib must be based on the following criteria:

a.    Base Electrocardiogram

b.    Base electrolyte as: K, Ca and Mg

c.     Base TSH

C.    By Triple-S, it is considered for payment for the treatment with vendetanib in the following conditions, identified by their corresponding ICD-10 codes.

D.    Triple-S does not consider for payment the use of vandetanib under the following circumstances:

a.    When there is documentation of:

i.    Congenital syndrome with prolongation of the QT segment

ii.    <18 years of age Off label indication;  Non-Small Cell Lung Cancer ; Patient’s tumor is confirmed to have RET gene rearrangements

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