Subject: Specialty Quantity Limit Qinlock 3904-H P2023

Drug

QINLOCK  (ripretinib)

Policy:

I.  PROGRAM DESCRIPTION

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. If the member’s plan allows a quantity limit exception review for the requested medication, coverage of an additional quantity may be provided up to the exception limit with prior
authorization.


II.  COVERED QUANTITIES

Medication	Standard      Limit	Exception         Limit*	FDA-recommended dosing
Qinlock   (ripretinib)   50 mg tablets	90 per 30 days	180 per 30 days	Recommended dosage: 150 mg once daily   Dose modifications may be required for adverse   reactions or use with moderate CYP3A4 inducers.

 *Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity
  Exception Criteria for approval.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Qinlock [package insert]. Waltham, MA: Deciphera Pharmaceuticals, LLC; December 2022.

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