Xtandi — CareFirst (Caremark)
Castration-resistant prostate cancer (CRPC)
Initial criteria
- For castration-resistant prostate cancer (CRPC): 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 (degarelix, relugolix).
- For metastatic castration-sensitive prostate cancer (mCSPC): 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 (degarelix, relugolix).
- For non-metastatic castration-sensitive prostate cancer (nmCSPC): Member has biochemical recurrence at high risk for metastasis.
Reauthorization criteria
- Continuation of therapy may be granted when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
Approval duration
12 months