Specialty Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan
Subject: Jevtana (cabazitaxel)
Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit. All criteria below must be met in order to obtain coverage of Jevtana (cabazitaxel).
Under some plans, including plans that use an open or closed formulary, Jevtana (cabazitaxel) is subject to precertification. If precertification requirements apply Aetna considers these drugs to be medically necessary for those members who meet the following precertification criteria:
The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.
All other indications are considered experimental/investigational and are not a covered benefit.
II. CRITERIA FOR INITIAL APPROVAL1-2
Metastatic castration-resistant prostate cancer (CRPC)
Authorization of 6 months may be granted for continued treatment in members requesting reauthorization for an indication listed in Section III when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
Place of Service:
The above policy is based on the following references:
December 4, 2020
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