Xtandi (enzalutamide) — Highmark
non-metastatic castration-sensitive prostate cancer with biochemical recurrence at high risk for metastasis
Initial criteria
- age ≥ 18 years
- For CRPC: diagnosis of castration-resistant prostate cancer (ICD-10: C61, Z19.2) AND Xtandi is being used in combination with a GnRH analog OR the member has had a bilateral orchiectomy
- For metastatic CSPC: diagnosis of metastatic castration-sensitive prostate cancer (ICD-10: C61, Z19.1) AND Xtandi is being used in combination with a GnRH analog OR the member has had a bilateral orchiectomy
- For non-metastatic CSPC: diagnosis of non-metastatic castration-sensitive prostate cancer (ICD-10: C61, D07.5) AND member has biochemical recurrence at high risk for metastasis
Reauthorization criteria
- Prescriber attests the member is tolerating therapy AND has experienced a therapeutic response defined as disease improvement OR delayed disease progression
Approval duration
up to 2 years