I. Initial Authorization
A. Erleada
When a benefit, coverage of Erleada may be approved when all of the following criteria are met (1. and 2.):
1. The member meets one (1) of the following criteria (a. or b.):
a. The member has a diagnosis of metastatic castration-sensitive prostate cancer.
b. The member has a diagnosis of non-metastatic castration-resistant prostate cancer.
2. The member meets one (1) of the following criteria (a. or b.):
a. Erleada is being used in combination with a GnRH analog.
b. The member has had a bilateral orchiectomy.
B. Nubeqa
When a benefit, coverage of Nubeqa may be approved when all of the following criteria are met (1. and 2.):
1. The member has a diagnosis of non-metastatic castration-resistant prostate cancer.
2. The member meets one (1) of the following criteria (a. or b.):
a. Nubeqa is being used in combination with a GnRH analog.
b. The member has had a bilateral orchiectomy.
C. Xtandi
When a benefit, coverage of Xtandi may be approved when all of the following criteria are met (1. and 2.):
1. The member meets one (1) of the following criteria (a. or b.):
a. The member has a diagnosis of castration-resistant prostate cancer.
b. The member has a diagnosis of metastatic castration-sensitive prostate cancer.
2. The member meets one (1) of the following criteria (a. or b.):
a. Xtandi is being used in combination with a GnRH analog.
b. The member has had a bilateral orchiectomy.
II. Reauthorization
When a benefit, reauthorization of Erleada, Nubeqa, or Xtandi may be approved when the following criterion is met (A.):
A. The prescriber attests that the member is tolerating therapy and has experience a therapeutic response defined as one (1) of the following (1. or 2.):
1. Disease improvement
2. Delayed disease progression
III. An exception to some or all of the criteria above may be granted for select members and/or circumstances based on state and/or federal regulations.
IV. Coverage of oncology medications listed in this policy may be approved on a case-by-case basis per indications supported in the most current NCCN guidelines.