Niraparib (Zejula)

ORAL ADMINISTRATION

Indications for Prior Authorization:

  • Maintenance treatment of adult patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer wo are in a complete or partial response to platinum-based chemotherapy.

Patients must meet the following criteria for the indication(s) above:

  • Prescribed by an oncologist, AND
  • Diagnosis of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer, AND
  • Received at least 2 prior platinum-containing regimens, AND
  • Currently in complete or partial response to platinum-based chemotherapy, AND
  • Will initiate therapy no later than 8 weeks after the most recent platinum-containing regimen, AND
  • Recovered from hematologic toxicity caused by previous chemotherapy prior to initiating therapy, AND
  • Will be used as monotherapy

Dosing:

  • 300 mg (three 100mg capsules) once daily

Approval:

  • 1 year

 

Last review date: June 12, 2017

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