Genetic Testing for BRCA-Related Cancer
Criteria
BRCA screening is allowed in the following instances:
• Members is over the age of 18; and
• Have at least one of the following criteria:
o Personal history of any of the following:
♦ Breast cancer diagnosis at or before age 45.
♦ Breast cancer diagnosis at or before age 50 with any of the following:
♦ An additional breast cancer primary;
• 1 or more close blood relative with breast cancer at any age;
• 1 or more close blood relative with pancreatic cancer;
• 1 or more close blood relative with prostate cancer with a Gleason score ≥7.
♦ Breast cancer diagnosis at or before age 60 with:
• Triple negative breast cancer.
♦ Breast cancer diagnosis at any age with any of the following:
• 1 or more close relatives with breast cancer diagnosed before age 50;
• 2 or more close blood relatives with breast cancer diagnosis at any age;
• 1 or more close blood relative with ovarian cancer diagnosis;
• 2 or more close blood relatives with pancreatic cancer diagnosis or prostate cancer diagnosis with a Gleason score ≥7;
• 1 or more close blood relative diagnosed with male breast cancer.
♦ Male breast cancer diagnosis at any age.
♦ Ovarian cancer diagnosis at any age.
♦ Fallopian tube cancer diagnosis at any age.
♦ Primary peritoneal cancer diagnosis at any age.
♦ Prostate cancer diagnosis with a Gleason score 7 at any age with any of the following:
• 1 or more close blood relative with ovarian cancer at any age;
• 1 or more close blood relative with breast cancer before age 50;
• 2 or more close blood relatives with breast,pancreatic, or prostate cancer (Gleason score ≥7) at any age.
♦ Pancreatic cancer diagnosis at any age with any of the following:
• Ashkenazi Jewish ancestry;
• 1 or more close blood relative with ovarian cancer at any age;
• 1 or more close blood relative with breast cancer before age SO;
• 2 or more close blood relatives with breast,pancreatic,or prostate cancer (Gleason score ≥7) at any age.
o Family history of any of the following:
♦ First or second degree blood relative who meet any of the above criteria.
♦ Third degree blood relative who has breast cancer and/or ovarian cancer and who has 2 or more close blood relatives with breast cancer (at least one with breast cancer before age SO) and/or ovarian cancer.
♦ 1 or more family member with a known potentially harmful mutation In the BRCAl or BRCA2 gene.
*Close blood relative includes first, second,and third degree relatives on the same side of the family.
**Breast cancer diagnosis includes invasive and ductal carcinoma in situ.
Prior Authorization Contact
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)