CurrentNeighborhood Health Plan of Rhode IslandPolicy 1810-A

Lynparza (olaparib) coverage criteria

Clinical coverage and prior authorization criteria for olaparib (Lynparza) across FDA-approved and compendial oncology indications (ovarian, breast, pancreatic, prostate, uterine leiomyosarcoma) for members of Neighborhood Health Plan of Rhode Island; establishes required documentation, authorization durations, and continuation limits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLynparza (olaparib) coverage criteria

Policy CodePolicy 1810-A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization with supporting documentation including laboratory reports confirming BRCA or HRR/HRD status, HR/HER2 status where applicable, and documentation of response and absence of unacceptable toxicity for initial and reauthorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Primary FDA or compendial tumor types covered

12Typical initial or renewal authorization length

2Max duration: ovarian first-line maintenance (complete response)

1Max duration: adjuvant early-stage breast

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OpenPayer

Lynparza (olaparib) coverage criteria

Indications and Medical Necessity Criteria