Zytiga — CareFirst (Caremark)
Prostate cancer
Initial criteria
- Member has had a bilateral orchiectomy OR will be using the requested medication with a luteinizing hormone-releasing hormone (LHRH) agonist (e.g., goserelin, leuprolide) or antagonist (e.g., degarelix, relugolix)
- AND one of the following: (a) disease is non-metastatic and node positive, high-risk, or very-high-risk; OR (b) disease is metastatic
- For salivary gland tumor: authorization may be granted for recurrent, unresectable, or metastatic salivary gland tumor in combination with prednisone when the tumor is androgen receptor positive
Reauthorization criteria
- No evidence of unacceptable toxicity or disease progression while on the current regimen
Approval duration
12 months