Zytiga (abiraterone acetate) — Highmark

Preferred products

• abiraterone acetate 250 mg tablets
• Abirtega

Initial criteria

• age ≥ 18 years
• Diagnosis of metastatic castration-resistant or metastatic high-risk castration-sensitive prostate cancer (ICD-10: C61)
• Use in combination with prednisone
• Used in combination with a GnRH analog OR member has had a bilateral orchiectomy
• If request is for brand Zytiga 500 mg tablets or generic abiraterone acetate 500 mg tablets, member has experienced therapeutic failure or intolerance to one of: abiraterone acetate 250 mg tablets OR Abirtega
• If request is for brand Zytiga 250 mg tablets, member has experienced therapeutic failure or intolerance to one of: abiraterone acetate 250 mg tablets OR Abirtega

Reauthorization criteria

• Prescriber attests member is tolerating therapy and has experienced disease improvement OR delayed disease progression
• If request is for brand Zytiga 500 mg tablets or generic abiraterone acetate 500 mg tablets, member has experienced therapeutic failure or intolerance to abiraterone acetate 250 mg tablets OR Abirtega
• If request is for brand Zytiga 250 mg tablets, member has experienced therapeutic failure or intolerance to abiraterone acetate 250 mg tablets OR Abirtega

Approval duration

12 months