Capecitabine Coverage Policy
Defines prior authorization and preferred product management for capecitabine tablets (generic preferred; Xeloda non-preferred) including exception criteria for non-preferred product coverage and documentation requirements. Applies to Cigna-administered health benefit plans as described.
Annual revisions listed with 'No criteria changes' for review dates 08/23/2023, 06/19/2024, and 06/18/2025.
Coverage Summary
This policy implements a Preferred Specialty Management program in which generic capecitabine tablets are the Preferred Product and Xeloda (brand capecitabine) is designated as Non-Preferred. The program requires patients to meet the standard Oncology - Capecitabine Prior Authorization criteria and directs use of the Preferred Product prior to approval of the Non-Preferred product. Coverage guidance and exception review apply to health benefit plans administered by Cigna companies.