When a benefit, coverage of Zytiga may be approved when one of the following criterion is met (A. or B.):
A. Zytiga is to be used in combination with prednisone for members diagnosed with metastatic castration-resistant prostate cancer (ICD-9 185, ICD-10 C61)
B. Zytiga is to be used in combination with prednisone for members diagnosed with metastatic high-risk castration-sensitive prostate cancer (ICD-9 185, ICD-10 C61)
I. For Commercial and Healthcare Reform members enrolled in a Delaware plan, an exception to select criteria within this policy may be made based on Policy J-651 – Delaware—Cancer Chemotherapy Override Exception—Commercial and Healthcare Reform.