CurrentNeighborhood Health Plan of Rhode IslandPolicy Yonsa 2596-A SGM P2023

Yonsa (abiraterone acetate) — Coverage Criteria

This policy governs coverage and authorization criteria for Yonsa (abiraterone acetate) in members of Neighborhood Health Plan of Rhode Island, focusing on its use in metastatic castration‑resistant prostate cancer and compendial uses; it excludes non‑recommended combinations and non‑compendial indications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyYonsa (abiraterone acetate) — Coverage Criteria

Policy CodePolicy Yonsa 2596-A SGM P2023

Change TypeNo material change

Effective Date

Next Review Date

Key ActionRequest prior authorization for up to 12 months and document FDA‑approved or compendial indication and absence of excluded drug combinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsAuthorization duration

FDA + compendialCovered indications

Combinations excludedExcluded combinations

Coverage and Authorization Criteria

Covered Indications

Covered when ALL of the following are met:

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FDA or compendial indication: The use is an FDA‑approved indication (Yonsa in combination with methylprednisolone for metastatic castration‑resistant prostate cancer) OR a compendial use for prostate cancer as listed in recognized compendia.

Supported by chunks 0-2

Approval criteria met and no exclusions: All approval criteria in this policy are met and the member has no exclusions to the prescribed therapy.

Supported by chunk 0

Metastatic castration‑resistant prostate cancer authorization

Authorization condition for metastatic castration‑resistant prostate cancer:

Castration status or concurrent ADT: Member has had a bilateral orchiectomy OR will be using Yonsa in combination with a gonadotropin‑releasing hormone (GnRH) agonist or degarelix.

Supported by chunk 4

Continuation Therapy

Reauthorization (Continuation of therapy):

No progression or unacceptable toxicity: Authorization of up to 12 months may be granted for continued treatment when there is no evidence of disease progression or unacceptable toxicity while on the current regimen.12 months

Supported by chunks 5 and 4 (duration and ADT documentation requirement)

Billing, Codes, and Authorization Length

No explicit billing codes providedmixed

No codes listed

Authorization duration — standard granted duration for initial or continuation therapy

Standard authorization duration12 months for initial treatment or continuation when criteria are met

Condition for metastatic CRPC initial authorizationMember has had bilateral orchiectomy or will use Yonsa with a GnRH agonist or degarelix

Continuation (reauthorization) condition12-month authorization may be granted when there is no unacceptable toxicity or disease progression on the current regimen

Provider Requirements, Documentation, and Denial Conditions

Documentation Required

Indication and exclusion documentation

Document the FDA‑approved or compendial indication for the requested therapy. For prostate cancer indications, confirm the use is an FDA‑approved indication or a compendial use; all other indications are not medically necessary and are excluded.

State the specific FDA‑approved or compendial indication
Include supporting documentation (e.g., diagnosis, clinical notes, relevant pathology/imaging, prior therapy history)

Prior Authorization

Prior authorization duration and surgical/concurrent ADT documentation

Prior authorization of up to 12 months may be granted when criteria are met. For metastatic castration‑resistant prostate cancer (mCRPC), document bilateral orchiectomy or concurrent use of a GnRH agonist/antagonist (e.g., degarelix) when applicable. Reauthorization may be granted for 12 months if there is no unacceptable toxicity or disease progression while on the current regimen.

For mCRPC, include documentation of bilateral orchiectomy OR planned/ongoing concurrent GnRH agonist/antagonist
For reauthorization, provide evidence of clinical benefit and absence of unacceptable toxicity or progression

Denial Risk

Excluded drug combinations — denial risk

Do not submit requests for use in combination with second‑generation oral anti‑androgens (e.g., apalutamide) or oral androgen metabolism inhibitors (e.g., abiraterone). Such combinations are excluded and will result in denial.

Examples of excluded combinations: apalutamide (Erleada), abiraterone acetate (Zytiga)

Step Therapy

Step therapy

No explicit step therapy is required; coverage is limited to FDA‑approved and compendial uses as documented above.

Absence of step therapy — ensure indication meets FDA or compendia criteria

Drug Background

Yonsa (abiraterone acetate) is an oral androgen biosynthesis inhibitor indicated for use in prostate cancer when combined with corticosteroid therapy; in clinical practice it is typically prescribed in combination with prednisone or methylprednisolone for treatment of metastatic castration‑resistant prostate cancer (mCRPC). When used for mCRPC under this policy, authorization may require documentation of castration status (for example, bilateral orchiectomy or concurrent gonadotropin‑releasing hormone [GnRH] agonist/degarelix therapy) and is granted according to the policy’s criteria and duration limits.

Definitions and Scope

FDA‑approved indication — Yonsa indicated with methylprednisolone for metastatic castration‑resistant prostate cancer

FDA‑approved indication (drug + steroid)Yonsa is indicated in combination with methylprednisolone for treatment of patients with metastatic castration‑resistant prostate cancer (CRPC)

Disease contextMetastatic castration‑resistant prostate cancer (CRPC)

Required concomitant steroid in indicationMethylprednisolone must be used in combination with Yonsa per the indication

Compendial use — statement that compendia-listed prostate cancer uses are considered covered when criteria are met

Compendial prostate cancer usesUses for prostate cancer listed in recognized compendia are considered covered when approval criteria are met

Non‑compendial indicationsAll other indications are considered experimental/investigational and not medically necessary

Relationship to FDA indicationCompendial uses supplement the FDA‑approved indication (Yonsa + methylprednisolone for metastatic CRPC) for coverage when criteria are met