CurrentNeighborhood Health Plan of Rhode IslandPolicy 2596-A

Yonsa (abiraterone acetate) — coverage criteria for metastatic castration‑resistant prostate cancer

Covers use of Yonsa (abiraterone acetate formulation) for FDA‑approved and compendial indications in members of Neighborhood Health Plan of Rhode Island when approval criteria are met; excludes non‑covered uses and specified combinations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyYonsa (abiraterone acetate) — coverage criteria for metastatic castration‑resistant prostate cancer

Policy CodePolicy 2596-A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization; approvals may be granted for up to 12 months when used for metastatic castration‑resistant prostate cancer with required documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsapproval duration

1FDA indication listed

1compendial indication

2references

Coverage Criteria for Yonsa (abiraterone acetate)

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Initial therapy — mCRPC

Covered when ALL of the following are met for metastatic castration‑resistant prostate cancer:

FDA indication: Yonsa used in combination with methylprednisolone for metastatic castration‑resistant prostate cancer.

Castration status: Member has had a bilateral orchiectomy OR will be using the requested medication in combination with an LHRH agonist (e.g., goserelin, leuprolide) or antagonist (e.g., degarelix, relugolix).

Authorization of up to 12 months may be granted when this requirement is met.

Continuation therapy

Covered for continuation when ALL of the following are met:

Ongoing benefit: Indication is listed in the coverage criteria (e.g., metastatic castration‑resistant prostate cancer).

Response/toxicity: No evidence of unacceptable toxicity or disease progression while on the current regimen.

Authorization of up to 12 months may be granted for continued treatment when these conditions are met.

Coverage will not be provided when Yonsa is prescribed in combination with a second‑generation oral antiandrogen (for example, apalutamide) or with an oral androgen metabolism inhibitor (for example, abiraterone acetate [Zytiga]). Such concurrent use is excluded from coverage and requests that document these combinations will be denied.

Use of Yonsa for indications other than FDA‑approved or the listed compendial prostate cancer uses is considered not medically necessary. Requests for coverage for unlisted indications will be declined.

All indications of Yonsa that are not FDA‑approved or included in the stated compendial prostate cancer category are considered experimental/investigational and are therefore excluded from coverage.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Yonsa. Approvals may be granted for up to 12 months when criteria are met, including when the member has had a bilateral orchiectomy or will be using Yonsa in combination with an LHRH agonist (e.g., goserelin, leuprolide) or antagonist (e.g., degarelix, relugolix). Continuation authorizations may be granted for 12 months when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Authorization duration: up to 12 months when criteria met
Examples of LHRH agents: goserelin, leuprolide, degarelix, relugolix

Denial Risk

Excluded Combinations — Denial Risk

Request will be denied if Yonsa is used in combination with a second‑generation oral antiandrogen (e.g., apalutamide [Erleada]) or an oral androgen metabolism/inhibitor (e.g., abiraterone acetate [Zytiga]).

Example excluded combinations: apalutamide (Erleada); abiraterone acetate (Zytiga)

Documentation Required

Required Clinical Documentation

Documentation must support a diagnosis of metastatic castration‑resistant prostate cancer (mCRPC) and prior treatments, including evidence of bilateral orchiectomy or documentation that the member will receive concurrent medical castration with an LHRH agonist or antagonist. For continuation requests, provide evidence of clinical benefit and absence of unacceptable toxicity or disease progression on current therapy.

Diagnosis: metastatic castration‑resistant prostate cancer (mCRPC)
Prior treatment evidence: bilateral orchiectomy OR plan for concurrent LHRH agonist/antagonist
For reauthorization: documentation showing no unacceptable toxicity and no disease progression

Key Definitions

Metastatic castration‑resistant prostate cancer (mCRPC)

DefinitionMetastatic castration‑resistant prostate cancer (mCRPC) is prostate cancer that has progressed despite castrate levels of testosterone.

FDA‑approved relationYonsa (fine‑particle abiraterone acetate) is indicated in combination with methylprednisolone for treatment of patients with metastatic castration‑resistant prostate cancer.

Compendial contextProstate cancer is listed as a compendial use; all other indications beyond FDA‑approved and listed compendial uses are considered experimental/investigational and not medically necessary.

Background

Yonsa (fine‑particle abiraterone acetate) is indicated in combination with methylprednisolone for the treatment of metastatic castration‑resistant prostate cancer (mCRPC). Authorization may be granted when approval criteria are met, typically for up to 12 months, and treatment should be provided with documentation of surgical castration (bilateral orchiectomy) or concomitant medical castration with an LHRH agonist/antagonist as required by the coverage criteria.