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Xtandi Prior Authorization: Key Steps You Should Know

As a healthcare provider, you’re no stranger to the complexities of prior authorizations, especially for high-cost medications like Xtandi (enzalutamide). It’s a critical treatment for advanced prostate cancer, but securing approval often involves detailed documentation, accurate coding, and effective communication with insurance providers.

This guide will help you streamline the process so you can spend less time on administrative tasks and more time focusing on patient care.

Understanding Insurance Company Policies

Insurance company policies for prior authorization vary based on the medication, diagnosis, and plan type (commercial, Medicare, or Medicaid). These policies are designed to control costs and ensure treatments like Xtandi (enzalutamide) are used appropriately. Understanding your patient’s specific plan is crucial—review the insurer’s formulary to confirm coverage, check for any step therapy requirements (e.g., trying other medications first), and familiarize yourself with submission guidelines and timelines. Being proactive about these details helps streamline the process and minimizes delays.

Why Prior Authorization is Essential for Xtandi?

Prior authorization is essential for Xtandi because of its high cost and specific use in treating advanced prostate cancer. Insurance providers require it to ensure the medication is medically necessary, aligns with approved indications like metastatic or castration-resistant prostate cancer, and follows their coverage policies. This process helps control costs while ensuring patients receive appropriate, evidence-based care tailored to their condition.

Step-by-Step Workflow for Prior Authorization

Step 1: Start with a Detailed Patient Consultation

Ensure that your initial documentation thoroughly supports the need for Xtandi. Include:

• The patient’s diagnosis (with ICD-10 codes) and current stage of cancer.
• Results of diagnostic tests, such as PSA levels, imaging results, or biopsy findings.
• A record of previous treatments and why they were insufficient (e.g., hormone therapy resistance).

Pro Tip: Insurers want to see a logical progression of care. Highlight how Xtandi is the next step in the treatment plan based on the patient’s history.

Step 2: Complete and Submit the Prior Authorization Form

This is a crucial step that should leave no gaps. The form must include:

• Patient demographics and insurance information.
• Specific details about the prostate cancer diagnosis.
• A detailed justification for prescribing Xtandi over alternative therapies.

Each insurance provider has unique forms and submission protocols. Be sure to follow their guidelines to avoid delays.

Step 3: Provide Comprehensive Supporting Documentation

Ensure all required documents are included in your submission, such as:

• Lab Results: PSA levels and other markers of disease progression.
• Imaging Reports: CT, MRI, or PET scans to demonstrate cancer metastasis.
• Prior Treatment Records: Show that alternative therapies were tried or are not suitable.
• Relevant Codes:
  • ICD-10: C61 (Malignant neoplasm of the prostate) and Z85.46 (Personal history of prostate cancer).
  • CPT Codes: Related to diagnostic tests or other procedures.

Pro Tip: Double-check the accuracy of all codes and documentation. Errors here are a common reason for denials.

Step 4: Follow Up with the Insurance Provider

After submission, call the insurance company to:

• Confirm receipt of the request.
• Clarify the expected timeline for a decision.

Typical Timelines:

• Routine cases: 2–14 business days.
• Expedited cases: As little as 72 hours (for urgent medical needs).

Step 5: Address Requests for Additional Information Promptly

If the insurer requests further clarification or additional documentation, respond quickly to prevent delays. Common requests include:

• More detailed lab results or imaging.
• A stronger explanation of medical necessity.

Pro Tip: Assign a specific team member to track and manage these follow-ups to ensure nothing falls through the cracks.

Step 6: Handle Denials and Appeals with Confidence

If your prior authorization is denied, don’t be discouraged. Here’s what to do:

1. Review the Denial Letter: Understand why the request was denied.
2. Submit Additional Evidence: Strengthen the case with updated records or a detailed narrative from the prescribing physician.
3. File an Appeal: Follow the insurer’s appeals process and provide all required materials promptly.

For urgent cases, request an expedited appeal to avoid treatment delays.

ICD and CPT Codes Explained

Insurance approvals often hinge on proper coding. These codes provide a standardized way to communicate the patient’s diagnosis and the rationale for treatment:

• ICD-10 Codes: C61 (Prostate cancer) and Z85.46 (History of prostate cancer).
• CPT Codes: Cover diagnostic tests, imaging, or any related procedures.

Incorrect codes are one of the most common reasons for delays or denials.

Frequently Asked Questions (FAQs)

How long does prior authorization take?

Routine requests: 2–14 business days.

Urgent cases: 72 hours or less.

What if the request is denied?

Review the denial letter and provide any missing documentation. File an appeal with a detailed explanation and additional evidence.

Are there patient assistance programs for Xtandi?

Yes, Xtandi Access Solutions offers co-pay assistance and support for eligible patients.

Can patients start Xtandi treatment before approval?

Some programs offer bridge therapy while waiting for insurance approval. Consult with the manufacturer or your patient’s insurance plan.

Is Xtandi covered by Medicare?

Yes, but coverage typically requires prior authorization under Medicare Part D.

What Did We Learn?

The prior authorization process for Xtandi may be intricate, but with a structured approach, it’s entirely manageable. Key takeaways for providers include:

• Ensure comprehensive documentation and accurate coding.
• Stay proactive with follow-ups to keep the process moving.
• Use patient assistance programs when necessary to prevent treatment interruptions.

For busy practices, outsourcing this process can be a game-changer.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of healthcare processes. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com.

References

https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-enzalutamide-metastatic-castration-sensitive-prostate-cancer