Medical Policy

Effective Date:04/01/2012 Title:Jevtana (Cabazitaxel)
Revision Date:10/01/2015 Document:BI347:00
CPT Code(s):J9043
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Jevtana (Cabazitaxel) requires prior authorization.

2)    Jevtana is considered a specialty medication.

3)    Jevtana is used to treat patients with metastatic prostate cancer.

Medical Statement

Jevtana is considered medically necessary for members who meet the following criteria:

1)    Diagnosis of hormone-refractory metastatic prostate cancer  (C61)


2)    Have previously been treated with a docetaxel-containing regimen


3)    Jevtana will be used in combination with prednisone.


Codes Used In This BI:

J9043             Cabazitaxel injection

Intentially left empty

1)    Jevtana Product Information.  Sanofi-Aventis.  June 2010.

2)    Clinical Pharmacology Online. “cabazitaxel”, retrieved December 2011.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.