UnitedHealthcare Rubraca Prior Auth Coverage | OpenPayer

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UnitedHealthcare Rubraca Prior Auth Coverage | OpenPayer

Coverage Criteria for Rubraca (rucaparib)

inv-01: Ovarian Cancer - Initial Therapy

Covered when ALL of the following are met

Ovarian Cancer - Initial Authorization: (1) Diagnosis of epithelial ovarian cancer, fallopian tube cancer, or primary peritoneal cancer; AND (2) cancer has a deleterious BRCA mutation; AND (3) to be used as maintenance therapy in individuals who are in complete or partial response to platinum-based chemotherapy.

Authorization will be issued for 12 months.

inv-02: Ovarian Cancer - Reauthorization

Covered when ALL of the following are met

Ovarian Cancer - Reauthorization: Patient does not show evidence of progressive disease while on Rubraca therapy.

Authorization will be issued for 12 months.

inv-03: Prostate Cancer - Initial Therapy

Covered when ALL of the following are met

Prostate Cancer - Initial Authorization: (1) Diagnosis of metastatic, castration-resistant prostate cancer; AND (2) cancer has a deleterious BRCA mutation; AND (3) history of failure, contraindication, or intolerance to androgen receptor-directed therapy (e.g., abiraterone, enzalutamide, apalutamide); AND (4) one of the following: used in combination with a gonadotropin-releasing hormone (GnRH) analog OR patient has had bilateral orchiectomy.

Authorization will be issued for 12 months.

inv-04: Prostate Cancer - Reauthorization

Covered when ALL of the following are met

Prostate Cancer - Reauthorization: Patient does not show evidence of progressive disease while on Rubraca therapy.

Authorization will be issued for 12 months.

inv-05: Uterine Leiomyosarcoma (uLMS) - Initial Therapy

Covered when ALL of the following are met

uLMS - Initial Authorization: (1) Diagnosis of BRCA altered uterine leiomyosarcoma (uLMS); AND (2) disease has progressed following prior treatment with gemcitabine plus docetaxel OR doxorubicin.

NCCN‑recommended setting; authorization will be issued for 12 months.

inv-06: Uterine Leiomyosarcoma - Reauthorization

Covered when ALL of the following are met

uLMS - Reauthorization: Patient does not show evidence of progressive disease while on Rubraca therapy.

Authorization will be issued for 12 months.

inv-07: Pancreatic Cancer - Initial Therapy

Covered when ALL of the following are met

Pancreatic Cancer - Initial Authorization: (1) Diagnosis of pancreatic adenocarcinoma; AND (2) presence of a deleterious or suspected deleterious germline or somatic BRCA1/2 mutation OR a deleterious or suspected deleterious germline or somatic PALB2 mutation; AND (3) disease has not progressed while receiving at least 16 weeks of a first-line platinum‑based chemotherapy regimen.>= 16 weeks

NCCN‑recommended maintenance setting; authorization will be issued for 12 months.

inv-08: Pancreatic Cancer - Reauthorization

Covered when ALL of the following are met

Pancreatic Cancer - Reauthorization: Patient does not show evidence of progressive disease while on Rubraca therapy.

Authorization will be issued for 12 months.

inv-09: Patients less than 19 years of age

Covered when the following is met

Pediatrics (<19): Patient is less than 19 years of age.

Prescription will automatically process without a coverage review; authorization will be issued for 12 months.

Some state mandates and federal requirements may supersede the criteria in this policy. Additionally, member-specific benefit plan provisions and other programs (including state off‑label coverage mandates and compendium requirements) can affect coverage and will take precedence where applicable. For members under the age of 19, the prescription will automatically process without a coverage review.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for Rubraca for covered indications. Initial and reauthorization requests must meet the clinical criteria specified by indication. Failure to meet the stated coverage criteria for members age 19 and older may result in denial of coverage.

Prior authorization required for members age 19 and older
Authorization durations: typically 12 months when approved (see indication-specific criteria)
Failure to meet criteria may result in denial

Step Therapy

Step/Failure Requirements by Indication

Step/failure requirements apply where specified by indication (for example, metastatic castration‑resistant prostate cancer requires prior failure, intolerance, or contraindication to androgen receptor–directed therapy; uterine leiomyosarcoma requires prior systemic therapies such as gemcitabine plus docetaxel or doxorubicin). Prescribers should document prior therapies, intolerances, or contraindications when applicable.

Prostate cancer: documented failure/intolerance/contraindication to androgen receptor–directed therapy (e.g., abiraterone, enzalutamide, apalutamide) required
uLMS: disease progression after prior treatment with gemcitabine + docetaxel or doxorubicin required

Note

Use of Claims and Medication History

UnitedHealthcare may approve initial or reauthorization requests based solely on prior claim or medication history, diagnosis codes (ICD-10), and/or automated claim logic. Use of these automated approval and re-approval processes varies by program and therapeutic class. Supply limits may apply.

Approvals may be based on prior claims/medication history and ICD-10 diagnosis codes
Automated approval/reapproval processes vary by program
Supply limits may be enforced

Denial Risk

Coverage Review and Denial Risk

Coverage review is required for members age 19 and older. Members under age 19 will have prescriptions automatically process without a coverage review when criteria for pediatric approval are met. If submitted documentation does not meet the policy criteria for adults, the request may be denied.

Members < 19 years: authorization issued for 12 months when pediatric criterion met and will process without coverage review
Members >= 19 years: coverage review required; failure to meet criteria may result in denial

Step Therapy / Prior Treatment Requirements

Step	Requirement / failure criteria
Step 1	For metastatic castration‑resistant prostate cancer: history of failure, contraindication, or intolerance to androgen receptor‑directed therapy (e.g., abiraterone, enzalutamide, apalutamide); AND therapy must be used in combination with a GnRH analog or the patient must have had bilateral orchiectomy.
Step 1	For uterine leiomyosarcoma (uLMS): disease progression following prior treatment with gemcitabine plus docetaxel OR doxorubicin.
Step 1	For pancreatic adenocarcinoma: disease has not progressed while receiving at least 16 weeks of a first‑line platinum‑based chemotherapy regimen.