Download MHCP Enrolled Providers – Pharmacies Fee-for

MHCP Enrolled Providers – Pharmacies
Fee-for-Service PA Criteria Sheet – Zytiga
(February 2013)
Drug
Therapeutic Area
Zytiga (abiraterone acetate) [Centocor Ortho Biotech]
Oral Oncology
Approval Criteria
 Patient has metastatic castration-resistant prostate cancer AND
 Will be on prednisone concurrently AND
 Has had previous chemotherapy with docetaxel OR
 Is not a chemotherapy candidate and in the pre-docetaxel setting
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Quantity Limits
 The initial PA will allow a first fill of 14 days [56 tablets (4 tablets once daily)] with one refill to ensure patient tolerance with
therapy before approving in larger, monthly quantities
Monthly Quantity Limit = 136
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Background information
Zytiga (abiraterone acetate) is indicated in combination with prednisone for the treatment of patients with metastatic castrationresistant prostate cancer (CRPC) who have previously received chemotherapy containing docetaxel.
The 1.2013 NCCN guidelines for prostate cancer place abiraterone acetate as an alternative to ketoconazole for patients with
metastatic disease without symptomatic visceral disease, or after docetaxel in patients with symptomatic visceral disease. Imitinib
is considered first-line treatment.
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MHCP Provider Call Center 651-431-2700 or 1-800-366-5411