Loading...

Neighborhood Health Plan RI lorlatinib Coverage | OpenPayer

v1.0.11

OpenPayerPolicy UpdatesHematology/OncologyNeighborhood Health Plan RI lorlatinib Coverage | …

CurrentNeighborhood Health Plan of Rhode IslandPolicy 2787-A

lorlatinib (Lorbrena) coverage

Defines prior authorization, coverage criteria, and documentation required for lorlatinib (Lorbrena) for Neighborhood Health Plan of Rhode Island members when used for FDA‑approved and specified compendial indications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policylorlatinib (Lorbrena) coverage

Policy CodePolicy 2787-A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization with chart documentation of ALK mutation or ROS1 rearrangement status; authorizations are generally granted for 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical authorization duration

ALK-positive NSCLCFDA-approved primary indication

ROS1 (post-progression)compendial NSCLC indication

Multiple tumor typescompendial uses listed

Coverage Criteria for lorlatinib (Lorbrena)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

FDA‑approved Indication (NSCLC)

Covered when ALL of the following are met:

FDA NSCLC indication: Adult patient with metastatic non-small cell lung cancer (NSCLC) whose tumors are ALK-positive as detected by an FDA-approved test.

Compendial NSCLC (ROS1) — single‑agent

Covered when ALL of the following are met:

ROS1 rearrangement-positive NSCLC post-progression: Disease is ROS1 rearrangement-positive AND disease has progressed on any of: crizotinib, entrectinib, repotrectinib, or taletrectinib.

Authorization may be granted for 12 months.

Inflammatory Myofibroblastic Tumor (IMT)

Covered when ANY of the following are met:

IMT coverage criteria: Treatment of ALK-positive inflammatory myofibroblastic tumor (IMT) as a single agent when either: the member has uterine sarcoma and the disease is advanced, recurrent, metastatic, or inoperable; OR the member has a soft tissue sarcoma (excluding uterine sarcoma).

Authorization may be granted for 12 months.

Erdheim‑Chester Disease

Covered when ALL of the following are met:

Erdheim‑Chester disease with ALK fusion: Treatment of ALK-positive Erdheim‑Chester disease as a single agent.

Authorization may be granted for 12 months.

Diffuse Large B‑Cell Lymphoma (DLBCL)

Covered when ALL of the following are met:

ALK-positive large B-cell lymphoma: Treatment of relapsed or refractory ALK-positive large B-cell lymphoma.

Authorization may be granted for 12 months.

Pediatric Diffuse High‑Grade Glioma (pHGG)

Covered when ALL of the following are met:

pediatric HGG ALK-rearranged: Treatment of ALK-rearrangement positive pediatric diffuse high-grade glioma when either: the disease is recurrent or progressive and the member does not have IDH-mutant and 1p/19q codeleted oligodendroglioma or IDH-mutant astrocytoma; OR the request is for adjuvant treatment and the member does not have disease that is diffuse midline, H3 K27-altered, or pontine.

Authorization may be granted for 12 months.

Anaplastic Large Cell Lymphoma (ALCL)

Covered when ALL of the following are met:

Relapsed/refractory ALK-positive ALCL: Treatment of relapsed or refractory ALK-positive anaplastic large cell lymphoma (ALCL) as a single agent.

Authorization may be granted for 12 months.

Reauthorization / Continued Therapy

Covered when ALL of the following are met:

Continued benefit: Continued treatment (reauthorization) is allowed for indications listed in coverage when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Authorization periods are typically 12 months.

All indications not specifically listed in the policy’s FDA‑approved indications or compendial uses are considered experimental/investigational and therefore not medically necessary.

Indications that are not included in the FDA‑approved indications section or the compendial uses section of this policy are considered not medically necessary (experimental/investigational) and are not eligible for coverage under this policy.

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for lorlatinib. Authorizations are generally granted for 12 months for initiation and reauthorization when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Authorization duration: 12 months for initiation and reauthorization when clinically appropriate.

Step Therapy

Prior Therapies Required for ROS1 NSCLC

For ROS1 rearrangement-positive non‑small cell lung cancer (NSCLC), lorlatinib is covered as single‑agent therapy only after disease progression on one of the following prior therapies: crizotinib, entrectinib, repotrectinib, or taletrectinib.

Required prior therapies for ROS1 NSCLC: crizotinib; entrectinib; repotrectinib; taletrectinib.

Documentation Required

Documentation Required for Prior Authorization

Submission of chart documentation indicating ALK mutation status or ROS1 rearrangement status (where applicable) is necessary to initiate the prior authorization review.

Clinical documentation must confirm ALK mutation status or ROS1 rearrangement status as relevant to the requested indication.

Line of Therapy Specifications

second-line

Second-line ROS1 NSCLC: ROS1 rearrangement-positive NSCLC after progression on crizotinib, entrectinib, repotrectinib, or taletrectinib.

first-line

First-line ALK-positive NSCLC: Adult metastatic ALK-positive non-small cell lung cancer (FDA-approved indication).

Biomarker and Test Requirements

inv-20: ALK — Detected by an FDA‑approved test (for NSCLC) or per compendial guidance.

BiomarkerALK rearrangement detected by an FDA‑approved test (for NSCLC)

Alternate detectionALK identified per compendial guidance for non‑NSCLC tumor types

Required documentationChart documentation indicating ALK mutation status must be submitted for prior authorization

inv-21: ROS1 — Definition and requirements for ROS1 testing / positivity.

DefinitionROS1 rearrangement-positive NSCLC: non‑small cell lung cancer with ROS1 rearrangement.

Line/condition for coverageCovered as single‑agent therapy only after disease progression on crizotinib, entrectinib, repotrectinib, or taletrectinib.

Required documentationChart documentation indicating ROS1 rearrangement status must be submitted for prior authorization

Definitions

inv-16: ALK-positive — Tumors demonstrating anaplastic lymphoma kinase (ALK) rearrangement as detected by an FDA‑approved test or per compendial guidance.

DefinitionTumors demonstrating anaplastic lymphoma kinase (ALK) rearrangement as detected by an FDA‑approved test.

Compendial applicabilityALK detection per compendial guidance is required for multiple non‑NSCLC tumor types (IMT, DLBCL, Erdheim‑Chester, ALCL, pediatric HGG).

Documentation for PAChart documentation indicating ALK mutation status must be submitted to initiate prior authorization review.

inv-17: ROS1 rearrangement-positive NSCLC (post-progression) — NSCLC with ROS1 rearrangement after progression on listed ROS1-targeted therapies (crizotinib, entrectinib, repotrectinib, or taletrectin...).

DefinitionROS1 rearrangement-positive NSCLC after progression on listed ROS1-targeted therapies (crizotinib, entrectinib, repotrectinib, or taletrectinib).

Coverage conditionAuthorization may be granted for 12 months when disease is ROS1 rearrangement-positive and has progressed on one of the listed agents.

Documentation for PAChart documentation indicating ROS1 rearrangement status must be submitted for prior authorization review.

Background

Lorlatinib (Lorbrena) is a targeted ALK inhibitor indicated for treatment of adult patients with metastatic ALK‑positive non‑small cell lung cancer and is also used across multiple compendial tumor types with ALK or ROS1 rearrangements. Coverage under this policy includes the listed FDA‑approved indication and specified compendial uses (for example, ROS1‑rearranged NSCLC post‑progression, ALK‑positive inflammatory myofibroblastic tumor, Erdheim‑Chester disease with ALK fusion, ALK‑positive large B‑cell lymphoma, pediatric diffuse high‑grade glioma, and ALK‑positive ALCL) when the criteria and required documentation are met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policylorlatinib (Lorbrena) coverage

Policy CodePolicy 2787-A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization with chart documentation of ALK mutation or ROS1 rearrangement status; authorizations are generally granted for 12 months.

SourceLink

On This Page

Coverage Criteria for lorlatinib (Lorbrena)Prior Authorization, Documentation, and Provider Requirements Line of Therapy Specifications Biomarker and Test Requirements Definitions Background