I. Zytiga
When a benefit, coverage of Zytiga may be approved when one of the following criteria are met (A. and B.):
A. Zytiga is used in combination with prednisone and the following:
1. The member has a diagnosis of castration-resistant prostate cancer.
2. The member has a diagnosis of metastatic high-risk castration-sensitive prostate cancer.
B. Documentation that generic abiraterone acetate is ineffective or not tolerated.
Quantity Limits
When a benefit, additional quantities of Zytiga 500 mg, up to 4 tablets per day, may be approved when the following criterion is met (A.):
A. The member is taking a strong CYP3A4 inducer.
II. Yonsa
When a benefit, coverage of Yonsa may be approved when all of the following criteria are met (A., B., and C.):
A. Yonsa is to be used in combination with methylprednisolone.
B. The member has been diagnosed with metastatic castration-resistant prostate cancer.
C. Documentation that generic abiraterone acetate is ineffective or not tolerated.
Quantity Limits
When a benefit, additional quantities of Yonsa 125 mg, up to 8 tablets per day, may be approved when the following criterion is met (A.):
A. The member is taking a strong CYP3A4 inducer.
III. 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.