ABIRATERONE ACETATE
Limited use benefit (prior approval required). Initial coverage criteria (Initial approval for 12 months) For the treatment of metastatic castration resistant prostate cancer patients (mCRPC) who are asymptomatic or mildly symptomatic after failure of androgen deprivation therapy (ADT) and who have not received prior chemotherapy if they meet the following criteria:
• Used in combination with prednisone; AND • Patient has an ECOG performance status of 0 or 1. For the treatment of metastatic castration resistant prostate cancer patients (mCRPC) who progressed on docetaxelbased chemotherapy if they meet the following criteria:
• Used in combination with prednisone; AND • Patient has an ECOG performance status ≤ 2; AND • Abiraterone is not used as an add-on therapy to enzalutamide (Xtandi); AND • Abiraterone has not been used in the pre-docetaxel setting.
Renewal coverage criteria (Renewal for 12 months)
There is no objective evidence of disease progression
250MG TABLET 02371065 ZYTIGA JSO
500MG TABLET 02457113 ZYTIGA JSO
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NIHB Drug Benefit List PDF