Neighborhood Health Plan RI olaparib Coverage | OpenPayer

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Neighborhood Health Plan RI olaparib Coverage | OpenPayer

Regimen	Indication	Coverage status
Olaparib + bevacizumab
First-line maintenance treatment of advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer in patients in complete or partial response to first-line platinum-based chemotherapy whose cancer is HRD-positive (defined by a deleterious or suspected deleterious BRCA mutation and/or genomic instability) or who have a deleterious or suspected deleterious germline or somatic BRCA mutation, and who received primary therapy that included bevacizumab
Covered

Regimen	Indication	Coverage status
Olaparib + abiraterone + steroid (prednisone/prednisolone/methylprednisolone)
Treatment of metastatic castration-resistant prostate cancer (mCRPC) in combination with abiraterone (or fine-particle abiraterone) and concurrent steroids for members with a deleterious or suspected deleterious BRCA mutation who have not progressed on prior novel hormone therapy and who are receiving concurrent LHRH agonist/antagonist therapy or have had bilateral orchiectomy
Covered with criteria

Regimen	Indication	Coverage status
Olaparib (single agent)
Maintenance treatment as a single agent after platinum-based chemotherapy for BRCA-mutated epithelial ovarian, fallopian tube, or primary peritoneal cancer in complete or partial response; and maintenance for deleterious or suspected deleterious germline BRCA-mutated metastatic pancreatic adenocarcinoma whose disease has not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen
Covered with criteria

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Standard approvals are for 12 months for most indications; specific maximum durations apply for certain settings (see continuation criteria).

Prior authorization required
Standard approval length: 12 months for most indications; see continuation rules for maximum durations

Documentation Required

Required Diagnostic Documentation

Submit diagnostic documentation to support the clinical indication. The following are required when applicable to the requested indication: laboratory reports confirming BRCA mutation status; laboratory reports confirming PALB2 mutation status; laboratory reports confirming germline or somatic homologous recombination repair (HRR) gene mutation status; hormone receptor (HR) and HER2 status; and homologous recombination deficient (HRD) status.

Laboratory report confirming BRCA mutation status (when applicable)
Laboratory report confirming PALB2 mutation status (when applicable)
Laboratory report confirming germline or somatic HRR gene mutation (when applicable)
Documentation of hormone receptor (HR) and HER2 status (when applicable)
Documentation of homologous recombination deficient (HRD) status (when applicable)

Documentation Required

Prerequisite Therapy and Molecular Findings for Prostate Cancer (mCRPC)

For metastatic castration‑resistant prostate cancer (mCRPC) requests, prerequisite therapy and molecular findings must be documented. When used as a single agent: member must have a deleterious or suspected deleterious germline or somatic HRR gene mutation (including BRCA1, BRCA2, ATM, BARD1, BRIP1, CDK12, CHEK1, CHEK2, FANCL, PALB2, RAD51B, RAD51C, RAD51D, RAD54L), must have progressed on prior androgen receptor‑directed therapy, and must be receiving concurrent LHRH agonist/antagonist therapy or have had bilateral orchiectomy. When used in combination with abiraterone (or fine‑particle abiraterone) plus concurrent steroids: member must have a deleterious or suspected deleterious BRCA mutation, must NOT have progressed on prior novel hormone therapy (e.g., abiraterone, enzalutamide, darolutamide, apalutamide), and must be receiving concurrent LHRH agonist/antagonist therapy or have had bilateral orchiectomy.

Single‑agent use: documented deleterious/suspected deleterious germline or somatic HRR gene mutation (see gene list)
Single‑agent use: documented progression on prior androgen receptor‑directed therapy
Single‑agent use: documentation of concurrent LHRH agonist/antagonist therapy or bilateral orchiectomy
Combination use with abiraterone + steroids: documented deleterious/suspected deleterious BRCA mutation
Combination use: no progression on prior novel hormone therapy (e.g., abiraterone, enzalutamide, darolutamide, apalutamide)
Combination use: documentation of concurrent LHRH agonist/antagonist therapy or bilateral orchiectomy

Denial Risk

Experimental/Investigational Exclusion

All other indications not listed in the coverage criteria are considered experimental/investigational and not medically necessary; requests for indications outside the policy will be reviewed but are generally denied.

Indications not specifically listed are considered experimental/investigational and not medically necessary

Biomarker and Genetic Testing Requirements

BRCA (germline or somatic) — deleterious or suspected deleterious

DefinitionDeleterious or suspected deleterious germline or somatic BRCA mutation (gBRCAm or sBRCAm).

Clinical relevanceRequired biomarker for most ovarian, breast, pancreatic, prostate, and select uLMS olaparib indications — select patients using an FDA‑approved companion diagnostic where indicated.

Ovarian indication noteIndicated for maintenance treatment in adult patients with BRCA‑mutated advanced or recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer in complete or partial response to platinum‑based chemotherapy.

Breast and pancreatic noteAuthorization for adjuvant or metastatic breast cancer and maintenance pancreatic cancer requires deleterious or suspected deleterious germline BRCA mutation.

HRD — HRD-positive defined by BRCA mutation and/or genomic instability

DefinitionHomologous recombination deficiency (HRD)–positive defined by either a deleterious or suspected deleterious BRCA mutation and/or genomic instability.

IndicationRequired for first‑line maintenance olaparib in combination with bevacizumab for advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer in CR/PR to first‑line platinum chemotherapy.

SelectionSelect patients based on an FDA‑approved companion diagnostic for Lynparza to determine HRD status.

Other HRR genes (e.g., ATM, PALB2, CHEK2, RAD51C/D, etc.) — deleterious or suspected deleterious

DefinitionDeleterious or suspected deleterious germline or somatic mutations in homologous recombination repair (HRR) pathway genes such as ATM, PALB2, CHEK2, RAD51C, RAD51D, and others listed for mCRPC eligibility.

Prostate relevanceFor mCRPC single‑agent use, member must have a deleterious or suspected deleterious HRR gene mutation (BRCA1, BRCA2, ATM, BARD1, BRIP1, CDK12, CHEK1, CHEK2, FANCL, PALB2, RAD51B, RAD51C, RAD51D, RAD54L).

Breast relevancePALB2 mutations may authorize olaparib for recurrent unresectable or metastatic breast cancer as a single agent where specified.