CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Yonsa (abiraterone acetate) — Coverage Criteria

Covers use of Yonsa (abiraterone acetate) for FDA‑approved and compendial prostate cancer indications when all approval criteria are met; defines exclusions for certain concomitant therapies and authorization durations for metastatic castration‑resistant prostate cancer. Applies to Neighborhood Health Plan of Rhode Island members managed under this policy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyYonsa (abiraterone acetate) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for Yonsa for metastatic castration‑resistant prostate cancer; authorization may be granted for up to 12 months when approval criteria are met and castration is in place.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration (initial)

12 moauthorization duration (continuation)

1FDA‑approved indication

2excluded concomitant classes

Coverage Criteria for Yonsa (abiraterone acetate)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyYonsa (abiraterone acetate) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Initial therapy for metastatic castration‑resistant prostate cancer

Yonsa is covered for FDA‑approved and compendial prostate cancer uses when all listed approval criteria are met.

FDA‑approved indication: Yonsa is indicated in combination with methylprednisolone for treatment of metastatic castration‑resistant prostate cancer (mCRPC).

Concomitant androgen suppression: Member has had bilateral orchiectomy OR will be using Yonsa in combination with a GnRH agonist or degarelix.

Authorization of 12 months may be granted when this criterion is met.

No excluded concomitant therapies: Member is not receiving Yonsa in combination with a second‑generation oral anti‑androgen (e.g., apalutamide) or an oral androgen metabolism inhibitor.

Requests combining Yonsa with excluded agents will be denied.

Provider Actions and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization required for Yonsa for metastatic castration‑resistant prostate cancer; authorization may be granted for 12 months when criteria are met.

Authorization may be granted for up to 12 months for treatment of metastatic castration‑resistant prostate cancer when the member has had a bilateral orchiectomy or will be using the requested medication in combination with a GnRH agonist or degarelix.
Authorization of up to 12 months may be granted for continued treatment (reauthorization) when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Denial Risk

Excluded Concomitant Therapies — Denial Risk

Policy explicitly excludes use of Yonsa in combination with certain oral anti‑androgens or androgen metabolism inhibitors. Requests will be denied if Yonsa is used concurrently with these excluded agents.

Examples of excluded concomitant therapies: second‑generation oral anti‑androgens (e.g., apalutamide [Erleada]).
Oral androgen metabolism inhibitors (e.g., abiraterone acetate [Zytiga]).
No step therapy sequencing is required or allowed to substitute for these exclusions.

Prior Authorization

Authorization Requirements for mCRPC

Authorization of up to 12 months may be granted when initial criteria are met for metastatic castration‑resistant prostate cancer.

Member must meet FDA‑approved indication (Yonsa in combination with methylprednisolone for metastatic castration‑resistant prostate cancer).
Member has had bilateral orchiectomy or will remain on medical castration with a GnRH agonist or degarelix.
Do not authorize if the requested use is concurrent with an excluded oral second‑generation anti‑androgen or an oral androgen metabolism inhibitor.

Documentation Required

Reauthorization / Continuation Documentation

Authorization of up to 12 months may be granted for continued therapy when there is no evidence of unacceptable toxicity or disease progression.

Reauthorization requires documentation demonstrating clinical benefit and absence of unacceptable toxicity or disease progression while on the current regimen.

Definitions and Compendial Use

Compendial use

DefinitionUses supported by drug compendia (e.g., NCCN Drugs & Biologics Compendium) that are considered covered benefits when all approval criteria are met.

ScopeApplies to prostate cancer compendial uses of Yonsa; these uses are covered provided all approval criteria are met and there are no exclusions to the prescribed therapy.

ExclusionsAll other indications beyond the compendial prostate cancer uses are considered experimental/investigational and not medically necessary.

Relation to FDA indicationsCompendial uses are accepted in addition to FDA‑approved indications when approval criteria are satisfied.

Documentation requirementMember must meet the policy’s approval criteria for coverage of compendial uses.

OpenPayer

Yonsa (abiraterone acetate) — Coverage Criteria

Coverage Criteria for Yonsa (abiraterone acetate)

Provider Actions and Authorization Rules

Definitions and Compendial Use

Background