CurrentCignaPolicy N/A

Oncology - Abiraterone Acetate Preferred Specialty Policy

Defines Cigna's coverage and prior authorization requirements for abiraterone acetate products (generic and brand Zytiga) under the Preferred Specialty Management program for oncology indications; applies to Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyOncology - Abiraterone Acetate Preferred Specialty Policy

Policy CodePolicy N/A

Change TypeAdministrative name change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that the member tried the preferred generic abiraterone acetate tablets before requesting brand Zytiga or provide prescriber documentation of a clinically significant reaction to the preferred product.

SourceLink

POLICY UPDATE CHANGES

The policy name was changed from 'Oncology - Abiraterone Acetate (Zytiga) Preferred Specialty Policy' to 'Oncology - Abiraterone Acetate Preferred Specialty Policy.'

1 yearApproval duration

Preferred/Non-PreferredProduct tiers

2Indications listed

65618, 65619Product IDs

Coverage Criteria

inv-01: Zytiga Exception Criteria

Zytiga is covered (approve for 1 year) when ALL of the following are met:

Zytiga Exception Criteria: A) Individual meets the standard Oncology - Abiraterone Acetate Prior Authorization Policy criteria; AND B) Individual has tried generic abiraterone acetate tablets; AND C) Individual cannot continue to use the Preferred medication due to a formulation difference in the inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) which, per the prescriber, would result in a significant allergy or serious adverse reaction.

Documentation required

inv-02: Preferred Product Approval

If standard prior authorization criteria are met but exception criteria (1B and/or 1C) for Zytiga are not met:

Approve Preferred Product: Approve generic abiraterone acetate tablets.

Any exception request not explicitly listed in the policy is considered not medically necessary. Requests that attempt to use criteria outside the specified exception pathways will be denied.

Policy Summary

PayerCigna

PolicyOncology - Abiraterone Acetate Preferred Specialty Policy

Policy CodePolicy N/A

Change TypeAdministrative name change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for all abiraterone acetate medications. Members must meet the Oncology - Abiraterone Acetate (Zytiga) Prior Authorization Policy criteria for both Preferred and Non-Preferred products. All approvals are provided for the duration specified in the policy.

All abiraterone acetate products require prior authorization.
Approvals are granted per the policy-specified duration.

Step Therapy

Preferred-First Requirement

The program requires the individual to try the Preferred Product (generic abiraterone acetate tablets) prior to approval of a Non-Preferred Product (Zytiga). If the individual meets the Oncology - Abiraterone Acetate Prior Authorization criteria but has not tried the Preferred Product, approval will be authorized for the Preferred Product instead of the Non-Preferred.

Preferred Product: generic abiraterone acetate tablets
Non-Preferred Product: Zytiga (brand)
Product Identifiers: 65618, 65619

Documentation Required

Documentation is required where noted in the criteria (marked as [documentation required]). Acceptable documentation includes, but is not limited to, chart notes, prescription claims records, and prescription receipts. Documentation is specifically required to support exceptions such as formulation-related allergies or serious adverse reactions.

Examples of documentation: chart notes; prescription claims records; prescription receipts
Documentation required to support formulation-difference exception for Zytiga

Denial Risk

Denial for Other Exceptions

Requests that do not meet the exception criteria or the Oncology - Abiraterone Acetate Prior Authorization Policy criteria are considered not medically necessary and will be denied.

Zytiga (brand) may be approved for 1 year only when all exception criteria (A, B, and C) are met: A) meets standard prior authorization criteria; B) has tried generic abiraterone acetate; C) cannot use Preferred due to formulation difference causing significant allergy or serious adverse reaction (documentation required).
If exception criteria are not met, approve generic abiraterone acetate tablets when standard prior authorization criteria are met.
Any other exception is considered not medically necessary.

Definitions

Preferred Product (generic abiraterone acetate tablets)

Preferred product namegeneric abiraterone acetate tablets

Program requirementIndividual must meet the Oncology - Abiraterone Acetate (Zytiga) Prior Authorization Policy criteria for any abiraterone acetate medication.

Preferred-first policyThe program directs the individual to try the Preferred Product prior to approval of Non-Preferred products.

DocumentationDocumentation is required where noted in the criteria (e.g., chart notes, prescription claims records, prescription receipts).

Non-Preferred Product / Exception Criteria (Zytiga)

Brand productZytiga (abiraterone acetate)

Exception criteria for coverageApprove for 1 year when ALL of the following are met: A) individual meets the standard Oncology - Abiraterone Acetate Prior Authorization Policy criteria; B) individual has tried generic abiraterone acetate tablets; and C) individual cannot continue the Preferred medication due to a formulation difference in inactive ingredient(s) that, per the prescriber, would result in a significant allergy or serious adverse reaction (documentation required).

Fallback when exception criteria not metIf prior authorization criteria are met but exception criteria B and/or C are not met, approve generic abiraterone acetate tablets.

Product identifiers65618, 65619

Step Therapy

Step	Requirement	Coverage
1	Member must try the Preferred Product: generic abiraterone acetate tablets prior to approval of brand Zytiga.	Covered
Exception	Brand Zytiga may be approved if all of the following are met: A) member meets the standard Oncology - Abiraterone Acetate Prior Authorization Policy criteria; AND B) member has tried generic abiraterone acetate tablets; AND C) member cannot continue the Preferred medication due to a formulation difference in inactive ingredient(s) that, per the prescriber, would cause a significant allergy or serious adverse reaction (documentation required).	covered_with_criteria (approve for 1 year)
Fallback	If prior authorization criteria are met but exception criteria B and/or C are not met, approve generic abiraterone acetate tablets.	Covered

OpenPayer

Oncology - Abiraterone Acetate Preferred Specialty Policy

Coverage Criteria

Product Identifiers / Coding

Provider Actions and Requirements

Definitions

Initial Therapy and Preferred Product

Step Therapy

Background

65618	Product Identifier
65619	Product Identifier