Antiandrogens / Androgen Blockers prior authorization
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Prior authorization guideline for antiandrogen androgen-blocking drugs (Erleada, Nubeqa, Xtandi, Yonsa) governing initial and reauthorization approvals for members when prescribed and supervised by an oncologist.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Initial Authorization
Covered when ALL of the following are met
Approval length: 12 months
inv-02: Reauthorization
Reauthorization covered when ALL of the following are met
Approval length: 12 months
The policy lists no explicit exclusions. There are no separate exclusion statements or named patient populations that are specifically excluded from coverage for the antiandrogen/androgen blocker products addressed in this guideline.
The policy does not spell out a separate list of "not medically necessary" scenarios, but operationally a request would fail to meet criteria if the provider does not document that the drug is prescribed or supervised by an oncologist as androgen deprivation therapy (ADT). For reauthorization, the policy requires that the member shows evidence of tumor response; absence of that documented response would not meet reauthorization criteria.
Initial Therapy
inv-12: Initial therapy
Initial authorization criteria
Approval length: 12 months
Continuation / Reauthorization
inv-13: Reauthorization
Reauthorization requirements
Approval length: 12 months
Covered Drug Products / Codes
| Erleada | apalutamide (product name listed) |
| Nubeqa | darolutamide (product name listed) |
| Xtandi | enzalutamide (product name listed) |
| Yonsa | abiraterone acetate (product name listed) |
Provider Actions & Requirements
Prior authorization required for listed antiandrogens
Prior authorization is required for Erleada, Nubeqa, Xtandi, and Yonsa for both initial authorization and reauthorization; approvals are issued for 12 months.
- Products listed: Erleada, Nubeqa, Xtandi, Yonsa
- Approval length: 12 months
Therapy stages: initial and reauthorization covered
This prior authorization guideline covers both initial authorization and reauthorization (therapy stages listed as Initial Authorization and Reauthorization).
Required documentation to support authorization
Documentation must confirm the requested drug is FDA‑approved for the condition being treated and that treatment is prescribed or supervised by an oncologist as androgen deprivation therapy; for reauthorization, documentation must include evidence of tumor response.
- Initial: FDA‑approved indication and oncologist prescription/supervision
- Reauthorization: FDA‑approved indication, oncologist prescription/supervision, and evidence of tumor response
Denial triggers: lack of oncologist oversight or tumor response
Failure to provide evidence of tumor response on reauthorization or to show the drug is prescribed or supervised by an oncologist may result in denial of the request.
Definitions
Background
Antiandrogen/androgen blocker agents named in this guideline (Erleada, Nubeqa, Xtandi, Yonsa) are oncology therapies used as part of androgen deprivation therapy (ADT). The policy requires that treatment be prescribed or supervised by an oncologist to meet coverage criteria, and establishes that these agents are subject to prior authorization with an approval length of 12 months when criteria are met.
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