| Effective Date:04/01/2012 |
Title:Jevtana (Cabazitaxel)
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| Revision Date:10/01/2015
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Document:BI347:00
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| CPT Code(s):J9043
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Public Statement
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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.
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Medical Statement
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Jevtana is
considered medically necessary for members who meet the following criteria:
1)
Diagnosis of
hormone-refractory metastatic prostate cancer (C61)
AND
2)
Have
previously been treated with a docetaxel-containing regimen
AND
3)
Jevtana will
be used in combination with prednisone.
Codes Used In This BI:
J9043 Cabazitaxel injection
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Limits
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Intentially left empty
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Reference
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1)
Jevtana
Product Information. Sanofi-Aventis. June 2010.
2)
Clinical
Pharmacology Online. “cabazitaxel”, retrieved December 2011.
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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