Prior authorization required — submit diagnosis, prescriber specialty, age, and BRCA status

Prior authorization is required. Provider must document the member's diagnosis, that the drug was prescribed by or in consultation with an oncologist (or urologist for prostate cancer), the member's age (≥18 years), and documented deleterious or suspected BRCA mutation when required by the indication. Include prior therapies and dosing within plan limits as part of the submission.

• Document diagnosis of relevant cancer (eg, epithelial ovarian, fallopian tube, primary peritoneal, or metastatic CRPC).
• Document prescriber specialty or consultation (oncologist; urologist for prostate cancer).
• Document age (≥ 18 years).
• When required by indication, document deleterious or suspected deleterious BRCA mutation status.
• Document prior therapies and requested dose (must be within plan-approved quantity limits).

Quantity limit — do not exceed plan-approved limits (1,200 mg/day; 4 tablets/day)

Ensure requests do not exceed the health-plan approved quantity limit. The policy's revised quantity limits cap dosing at 1,200 mg per day and a maximum of 4 tablets (or 4 capsules) per day.

• Maximum dose: 1,200 mg per day.
• Maximum tablets/capsules: 4 tablets or 4 capsules per day.
• Request must not exceed the member's health-plan approved quantity limit.

Generic substitution required when available; prior PARP inhibitor use disqualifies initiation

When generic rucaparib is available, providers should use the generic formulation unless contraindicated or clinically significant adverse events occur. Members who have previously received any PARP inhibitor are ineligible to initiate rucaparib for covered indications.

• Use generic rucaparib if available unless contraindicated or adverse events prevent substitution.
• Do not initiate rucaparib if the member has previously received a PARP inhibitor (eg, olaparib, talazoparib, niraparib, berzosertib/Akeega listed as examples).

Prior therapy for mCRPC — document failure of an androgen receptor‑directed therapy

For metastatic castration‑resistant prostate cancer (mCRPC) initial approvals, document prior failure of an androgen receptor‑directed therapy (for example, abiraterone or enzalutamide) unless such therapies are contraindicated or not tolerated.

• Record specific androgen receptor‑directed therapy tried (eg, abiraterone, enzalutamide, darolutamide, apalutamide).
• If therapies were not used due to contraindication or intolerance, document the clinical rationale.

Clinical documentation — include office notes, labs, and objective evidence

Submit supporting clinical documentation with the prior authorization request such as office chart notes, laboratory results, or other clinical information demonstrating the member meets all approval criteria.

• Include objective evidence of response or disease status per indication (eg, documentation of complete or partial response to platinum-based chemotherapy for ovarian indications).
• Provide mutation testing results when BRCA or other mutation status is required.

Required clinical documentation — concurrent ADT/orchiectomy and dosing/strengths

For metastatic CRPC patients, prescribers should document concurrent GnRH analog therapy or prior bilateral orchiectomy, and include the prescribed dosing and product strengths (tablets available in 200 mg, 250 mg, 300 mg).

• Document concurrent systemic ADT (GnRH analog) or prior bilateral orchiectomy.
• Document prescribed dose (eg, 600 mg PO twice daily for mCRPC) and tablet strength(s) used.

Documentation requirement — incomplete documentation may trigger denial

Failure to submit required documentation (office notes, labs, or other clinical information) demonstrating that the member meets the approval criteria may result in denial of the request.

• Ensure BRCA/mutation test results, prior therapy history, prescriber consultation notes, and dosing information are included to avoid denial.

Withdrawal-related denial risk — do not initiate for 3rd-line BRCA‑mutated ovarian indication

Do not initiate rucaparib for adult patients with deleterious BRCA‑mutated ovarian, fallopian tube, or primary peritoneal cancer who have been treated with two or more chemotherapies; the manufacturer voluntarily withdrew this indication effective June 10, 2022 and such requests may be denied.

• Withdrawal effective June 10, 2022 based on ARIEL4 overall survival detriment (HR 1.31).
• Physicians should not start new treatment for this withdrawn third‑line BRCA‑mutated ovarian indication.

Second‑line ovarian maintenance restriction — limited to BRCA‑mutated patients; prescriber attestation may be required

Use of rucaparib as second‑line ovarian maintenance for patients without BRCA mutations is restricted due to an increased risk of death observed in ARIEL3; prescriber attestation acknowledging this risk may be required for continuation or exceptional cases.

• Second‑line maintenance indication is limited to BRCA‑mutated patients per Appendix F.
• Patients without BRCA mutations had increased risk of death; document prescriber attestation if continuation is requested for a patient affected by the restriction.