Pharmacy Prior Authorization Criteria

Jevtana (cabazitaxel)

Indications for Prior Authorization

Jevtana (cabazitaxel)

• For diagnosis of Prostate Cancer
  Indicated in combination with prednisone for the treatment of patients with metastatic castration-resistant prostate cancer previously treated with a docetaxel-containing treatment regimen.

Criteria

Jevtana

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• All of the following:
• Diagnosis of metastatic castration-resistant prostate cancer
AND
• Used in combination with prednisone
AND
• Patient has been previously treated with a docetaxel-containing regimen

Jevtana

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of progressive disease

P & T Revisions

2024-03-05, 2023-06-22, 2022-03-08, 2021-09-27, 2021-05-19, 2021-02-21, 2020-02-12

References

1. Jevtana Prescribing Information. Sanofi-Aventis U.S. LLC, Bridgewater, NJ. July 2023.

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Revision History

• 2024-03-05: 2024 Annual Review. No criteria changes. Background updates.
• 2023-06-22: Removed specialist requirement
• 2022-03-08: Annual Review
• 2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-19: Addition of EHB formulary to guideline, no changes to criteria
• 2021-02-21: Annual Review - No Changes
• 2020-02-12: Annual Review - No Changes

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