Medical Policy

Effective Date:04/01/2015 Title:Lynparza (Olaparib)
Revision Date:06/01/2021 Document:BI479:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Lynparza (Olaparib) requires prior authorization.

2)  Lynparza is used to treat a type of advanced ovarian cancer and invasive breast cancer.
Medical Statement

Lynparza (olaparib) is considered medically necessary for patients with advanced ovarian cancer and ALL of the following:

1)    BRCA-positive mutation  AND

2)    Prior therapy with 3 or more lines of chemotherapy  AND

3)    NO concurrent therapy with other agents for the treatment of ovarian cancer.

 

Lynparza (olaparib) is considered medically necessary for the maintenance treatment of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer in patients who are in a complete or partial response to platinum-based chemotherapy, as monotherapy.

 

Lynparza (olaparib) is considered medically necessary for patients with invasive breast cancer with the following characteristics:

1) HER-2 negative AND

2) BRCA-positive mutation AND

3) Prior therapy with chemotherapy in the neoadjuvant, adjuvant, or metastatic setting AND

4) If HR-positive must have either:

a.    Previous treatment with endocrine therapy OR

b.    Considered an inappropriate candidate therapy for endocrine therapy

 

Lynparza (olaparib) is considered medically necessary for adult patients with deleterious or suspected deleterious gBRCAm metastatic pancreatic adenocarcinoma whose disease has not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen.

 

Lynparza (olaparib) is considered medically necessary for the treatment of adult patients with deleterious or suspected deleterious germline or somatic homologous recombination repair (HRR) gene-mutated metastatic castration-resistant prostate cancer (mCRPC) who have progressed following prior treatment with enzalutamide or abiraterone

Limits

As a specialty medication, Lynparza is limited to no more than a 30-day supply per fill.

Reference

1)    Lynparza Prescribing Information.  Astra Zeneca.  March 2021.

2)    NCCN Compendium.  Accessed online 3/27/2021.

3)    Clinical Pharmacology.  Accessed online 5/14/2018.

 

Addendum:

Effective 08/01/2018: Updated to include invasive breast cancer diagnosis.

Effective 01/01/2019:  Updated to include maintenance treatment of recurrent ovarian, fallopian tube, or primary peritoneal cancer in patients with complete or partial response to platinum-based chemo.

Effective 06/01/2021: Updated to include pancreatic adenocarcinoma and prostate cancer.

 

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.