CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

enzalutamide (Xtandi) for prostate cancer

Defines covered indications, exclusions, authorization durations, and continuation criteria for enzalutamide (Xtandi) including FDA-approved and compendial uses for prostate cancer. Applies when approval criteria are met and member has no exclusions to the prescribed therapy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyenzalutamide (Xtandi) for prostate cancer

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionAuthorization may be granted for 12 months per indicated diagnosis and requires meeting indication-specific requirements (e.g., bilateral orchiectomy or concurrent LHRH agonist/antagonist for CRPC and mCSPC).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

3FDA-Approved Indications Listed

1Compendial Indication Category

12Standard Authorization Duration (months)

Coverage Summary

Defines coverage for FDA-approved and compendial prostate cancer indications for enzalutamide (Xtandi) — specifically CRPC, mCSPC, and nmCSPC with high-risk BCR — and states that these uses are covered only when all approval criteria are met and the member has no exclusions to the prescribed therapy.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions & Prior Authorization

Prior Authorization

Authorization required

Authorization may be granted for 12 months per indicated diagnosis. Authorization requires meeting indication-specific requirements such as bilateral orchiectomy or concurrent use of an LHRH agonist (e.g., goserelin, leuprolide) or antagonist (degarelix, relugolix) for CRPC and mCSPC; 12-month authorization may also be granted for nmCSPC with high-risk BCR when criteria are met.

Documentation Required

Document orchiectomy or LHRH use for some indications

For CRPC and mCSPC, the provider must document that the member has had a bilateral orchiectomy or will be using the medication in combination with an LHRH agonist (e.g., goserelin, leuprolide) or antagonist (degarelix, relugolix) to support authorization.

Denial Risk

Combination therapy exclusions

Claims will not be covered if enzalutamide is used in combination with certain other agents; use with these agents is an exclusion and may result in denial of coverage.

Second-generation oral anti-androgen: apalutamide (Erleada)
Oral androgen metabolism inhibitor: abiraterone acetate (Zytiga)

Background

Specifies that the policy covers enzalutamide (Xtandi) for FDA‑approved prostate cancer indications and compendial prostate cancer uses when approval criteria are met and the member has no exclusions, and that other indications are considered investigational/not medically necessary.

Policy-specific Statistics

Standard Authorization Duration12 months

FDA-Approved Indications Listed3

Compendial Indication Category1

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyenzalutamide (Xtandi) for prostate cancer

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

enzalutamide (Xtandi) for prostate cancer

Coverage Summary

Continuation Therapy Criteria

Exclusions and Not Covered Uses

Applicable Codes

Provider Actions & Prior Authorization

Clinical Evidence & References

Background

Revision History