Cabazitaxel (Jevtana) (CPB 0806, reviewed 2026-03-12)

By 2026-03-12: Billing team must update prior authorization and claim adjudication rules in billing system to align with new Jevtana coverage criteria. Specifically: (1) Ensure claims for J9043 and J9064 are only approved when patient has documented prior treatment with docetaxel-containing regimen OR novel hormone therapy (enzalutamide/abiraterone) OR has small cell/neuroendocrine prostate cancer diagnosis; (2) Implement automated denial rules for claims when neutrophil counts ≤1,500 cells/mm3 or total bilirubin >3x ULN (lab values must be requested/verified before authorization); (3) Update denial logic to flag concomitant cabazitaxel + abiraterone combinations as experimental/not covered; (4) Flag all off-label indications (bladder cancer, breast cancer, lung cancer, etc.) as experimental/not covered and route to medical review; (5) Update encounter form templates and prior auth request forms to require documentation of prior chemotherapy or hormone therapy treatment history and current lab values (neutrophil count, bilirubin). Medical review staff should deny requests that do not meet criteria. Providers must submit prior authorization with evidence of prior treatment regimen before dispensing.