Subject: Nubeqa 3147-A SGM P2024
Policy:
I. INDICATIONS
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.
A. FDA-Approved Indications
1. Nubeqa is indicated for the treatment of adult patients with non-metastatic castration-
resistant prostate cancer (nmCRPC).
2. Nubeqa is indicated for the treatment of adult patients with metastatic hormone-sensitive
prostate cancer (mHSPC) in combination with docetaxel.
B. Compendial Use
Prostate Cancer
All other indications are considered experimental/investigational and not medically necessary.
II. EXCLUSIONS
Coverage will not be provided if the requested medication is used in combination with a
second-generation oral anti-androgen (e.g., apalutamide [Erleada]) or an oral androgen
metabolism inhibitor (e.g., abiraterone acetate [Zytiga]).
III. CRITERIA FOR INITIAL APPROVAL
Prostate Cancer
Authorization of 12 months may be granted when either of the following criteria are met:
1. The member has non-metastatic castration-resistant prostate cancer and the 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 (e.g., degarelix, relugolix).
2. The member has metastatic castration-sensitive prostate cancer and meets both of the
following criteria:
i. The requested medication will be used in combination with docetaxel
ii. The member has had a bilateral orchiectomy or will be using the requested medication
in combination with a LHRH agonist or antagonist.
IV. CONTINUATION OF THERAPY
Authorization of 12 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:
Outpatient
The above policy is based on the following references:
- Nubeqa [package insert]. Whippany, NJ: Bayer Healthcare Pharmaceuticals Inc.; October 2023.
- The NCCN Drugs & Biologics Compendium™ © 2024 National Comprehensive Cancer Network, Inc. https://www.nccn.org Accessed July 2, 2024.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
November 03, 2024
