Subject: Specialty Quantity Limit Ayvakit 3492-H P2023

Drug

AYVAKIT  (avapritinib)

Policy:

I.  PROGRAM DESCRIPTION

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.


II.  COVERED QUANTITIES

Medication	Standard Limit	FDA-recommended dosing
Ayvakit (avapritinib)   25 mg tablet	30 per 30 days	•   Recommended dosage:   •   Gastrointestinal Stromal Tumor (GIST): 300 mg orally        once daily on an empty stomach, at least one hour        before or two hours after a meal   •   Advanced Systemic Mastocytosis (AdvSM): 200 mg        orally once daily on an empty stomach, at least one        hour before or two hours after a meal   •   Indolent Systemic Mastocytosis (ISM): 25 mg orally        once daily on an empty stomach, at least one hour        before or two hours after a meal      º  Dose reductions may be needed for adverse          reactions, drug interactions or severe hepatic          impairment
Ayvakit (avapritinib)   50 mg tablet	30 per 30 days
Ayvakit (avapritinib)   100 mg tablet	30 per 30 days
Ayvakit (avapritinib)   200 mg tablet	30 per 30 days
Ayvakit (avapritinib)   300 mg tablet	30 per 30 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Ayvakit [package insert]. Cambridge, MA: Blueprint Medicines Corporation.; May 2023.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

December 31, 2023