darolutamide — CareFirst (Caremark)

Initial criteria

• Coverage will not be provided if the requested medication is used in combination with a second-generation oral anti-androgen (e.g., apalutamide [Erleada]) or an oral androgen metabolism inhibitor (e.g., abiraterone acetate [Zytiga]).
• Authorization may be granted when either of the following criteria are met:
• 1. The member has non-metastatic castration-resistant prostate cancer and the member has had a bilateral orchiectomy or will be using the requested medication in combination with a luteinizing hormone-releasing hormone (LHRH) agonist (e.g., goserelin, leuprolide) or antagonist (e.g., degarelix, relugolix).
• OR
• 2. The member has metastatic castration-sensitive prostate cancer AND meets both of the following criteria:
• • The member has high-volume synchronous or metachronous metastases and requested medication will be used in combination with or without docetaxel.
• • The member has had a bilateral orchiectomy or will be using the requested medication in combination with a LHRH agonist or antagonist.

Reauthorization criteria

• Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in the coverage criteria section when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Approval duration

12 months