CurrentClover HealthPolicy C22983-A

Jevtana (cabazitaxel) Coverage Criteria

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This policy governs Clover Health prior authorization criteria for Jevtana (cabazitaxel) in patients with metastatic castration-resistant prostate cancer. It applies to providers requesting initiation or continuation of therapy.

Policy Summary

PayerClover Health

PolicyJevtana (cabazitaxel) Coverage Criteria

Policy CodePolicy C22983-A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization establishing the diagnosis, continuation status, treatment benefit and tolerability when applicable, and required prior-treatment history or intolerance/non-candidacy for initiation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered diagnosis

3Specified prior therapies for initiation

2Continuation benefit and safety requirements

Coverage Criteria

Continuation Therapy

Covered when all of the following continuation requirements are met:

Continuation therapy

Diagnosis: Metastatic castration-resistant prostate cancer
Current treatment: The patient is currently receiving therapy with the requested medication.
Treatment benefit: The patient is receiving benefit from therapy.
No evidence of unacceptable toxicity and no evidence of disease progression while on the current regimen.

Initiation Therapy

Policy Summary

PayerClover Health

PolicyJevtana (cabazitaxel) Coverage Criteria

Policy CodePolicy C22983-A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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CurrentClover HealthPolicy C22983-A

Jevtana (cabazitaxel) Coverage Criteria

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Sign up for clover_health Policy C22983-A alerts

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Policy Summary

PayerClover Health

PolicyJevtana (cabazitaxel) Coverage Criteria

Policy CodePolicy C22983-A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered diagnosis

3Specified prior therapies for initiation

2Continuation benefit and safety requirements

Coverage Criteria

Continuation Therapy

Covered when all of the following continuation requirements are met:

Continuation therapy

Diagnosis: Metastatic castration-resistant prostate cancer
Current treatment: The patient is currently receiving therapy with the requested medication.
Treatment benefit: The patient is receiving benefit from therapy.
No evidence of unacceptable toxicity and no evidence of disease progression while on the current regimen.

Initiation Therapy

Policy Summary

PayerClover Health

PolicyJevtana (cabazitaxel) Coverage Criteria

Policy CodePolicy C22983-A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Initiation therapy

Diagnosis: Metastatic castration-resistant prostate cancer
Previously treated with at least one
- Docetaxel-containing regimen: Previously treated with a docetaxel-containing regimen.
- Enzalutamide: Previously treated with enzalutamide (Xtandi).
- Abiraterone: Previously treated with abiraterone (Zytiga).
Not a candidate for or intolerant to at least one
- Docetaxel-containing regimen: Not a candidate for or intolerant to a docetaxel-containing regimen.
- Enzalutamide: Not a candidate for or intolerant to enzalutamide (Xtandi).
- Abiraterone: Not a candidate for or intolerant to abiraterone (Zytiga).

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required

Jevtana requires prior authorization. For initiation or continuation requests, submit the patient's diagnosis, whether the patient is currently receiving Jevtana, evidence of treatment benefit, and applicable prior-treatment history and tolerability documentation.

Documentation Required

Prior Treatment and Intolerance or Non-Candidacy

Document whether the patient was previously treated with any of the specified therapies and, when applicable, whether the patient was not a candidate for or was intolerant to any of them.

Docetaxel-containing regimen
Enzalutamide (Xtandi)
Abiraterone (Zytiga)

Denial Risk

Diagnosis, Continuation, and Treatment Benefit

Approval requires documentation of metastatic castration-resistant prostate cancer. For continuation requests, confirm the patient is currently receiving Jevtana and is benefiting from therapy, with no unacceptable toxicity and no evidence of disease progression on the current regimen.

Diagnosis: metastatic castration-resistant prostate cancer
Continuation: patient is currently receiving the requested medication
Treatment benefit: no unacceptable toxicity and no disease progression

Step Therapy

Required Prior Therapy Evaluation

Denial risk increases when the required prior-therapy evaluation has not been completed. Document whether the patient has previously received any of the following treatments: a docetaxel-containing regimen, enzalutamide, or abiraterone.

Docetaxel-containing regimen
Enzalutamide (Xtandi)
Abiraterone (Zytiga)

Policy Background

Jevtana (cabazitaxel) is evaluated for patients with metastatic castration-resistant prostate cancer. The policy distinguishes between initiation and continuation: initiation requires specified prior-treatment history and evaluation of candidacy or intolerance, while continuation requires that the patient is currently receiving Jevtana and continues to benefit without unacceptable toxicity or disease progression.

Jevtana Initiation

Jevtana initiation requires both of the following:

Initiation requirements

Previous treatment
- Docetaxel-containing regimen: Previously treated with a docetaxel-containing regimen.
- Enzalutamide: Previously treated with enzalutamide (Xtandi).
- Abiraterone: Previously treated with abiraterone (Zytiga).
Non-candidacy or intolerance
- Docetaxel-containing regimen: Not a candidate for or intolerant to a docetaxel-containing regimen.
- Enzalutamide: Not a candidate for or intolerant to enzalutamide (Xtandi).
- Abiraterone: Not a candidate for or intolerant to abiraterone (Zytiga).

Jevtana Continuation

Jevtana continuation requires all of the following:

Continuation requirements

Current therapy: The patient is currently receiving therapy with the requested medication.
Ongoing clinical benefit: The patient is receiving benefit from therapy.
Benefit means no evidence of unacceptable toxicity and no evidence of disease progression while on the current regimen.