Pharmacy Policy Bulletin |
Androgen Receptor Inhibitors – Medicare | |
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Number: J-202 | Category: Prior Authorization |
Line(s) of Business:
Commercial |
Benefit(s):
Not applicable |
Region(s):
All |
Additional Restriction(s):
Applies to new starts only |
Drugs Products |
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FDA-Approved Indications: |
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Background: |
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Approval Criteria |
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I. Approval Criteria B. Nubeqa C. Xtandi II. For Medicare Part D beneficiaries, an androgen receptor inhibitor may be approved when used for a medically accepted indication as defined by the Centers for Medicare & Medicaid Services (CMS). |
Limitations of Coverage |
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None |
Authorization Duration |
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Automatic Approval Criteria |
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None |
Version: J-202-001 |
Effective Date Begin: 12/10/2019 |
Effective End Begin: 03/31/2020 |
Original Date: 11/06/2019 |
Review Date: 11/06/2019 |
References: