Ayvakit (avapritinib) prior authorization
Customize your policy alerts
Sign up for all careoregon policy alerts
Know when careoregon releases new policies or updates existing guidance.
Monitor payer policy activity
Prior authorization guideline for Ayvakit (avapritinib) for oncology indications (GIST and systemic mastocytosis) describing initial and reauthorization criteria and approval lengths for CareOregon members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Ayvakit (avapritinib)
inv-01: Initial Authorization - GIST
Covered when ALL of the following are met:
inv-02: Initial Authorization - Systemic Mastocytosis
Covered when ALL of the following are met:
inv-03: Reauthorization
Reauthorization covered when meeting the following timing and response rules:
The policy contains no explicit exclusions. Coverage requirements focus on meeting the specific diagnosis and prescriber criteria for Ayvakit (avapritinib) rather than listing disallowed indications or patient populations.
No additional non-coverage or "not medically necessary" items are specified in this guideline. The document sets diagnostic, prescriber, laboratory, and treatment-duration criteria that must be met for approval; absence of those criteria may result in denial but there are no separate unspecified-item rules provided.
Initial Authorization Details
inv-14: Initial Authorization — Initial authorization criteria and approval length
Initial authorization criteria and approval length:
Reauthorization / Continuation Criteria
inv-15: Reauthorization lengths — Reauthorization length depends on prior duration and stability on dose
Reauthorization length depends on prior duration and stability on dose:
Provider Requirements and Documentation
Prior authorization required; initial approval = 3 months
Prior authorization is required for Ayvakit (avapritinib). Initial authorizations are for 3 months and are for initial therapy only; the medication must be prescribed by an oncologist and meet diagnosis-specific criteria for coverage.
Consider prior TKI (e.g., imatinib) for GIST
For GIST, prior treatment with another tyrosine kinase inhibitor (for example, imatinib) is noted as a relevant consideration for some patients and may be part of the approval logic.
- Policy text: “Patient has been treated with another tyrosine kinase inhibitor in the past (e.g., imatinib).”
Required documentation: prescriber, diagnosis, mutation testing, platelet count
Include documentation showing the prescriber is an oncologist and the covered diagnosis. For GIST, provide supporting PDGFRA mutation testing; for systemic mastocytosis, document the SM subtype and the platelet count.
- GIST: evidence of PDGFRA mutation.
- Systemic mastocytosis: documentation of diagnosis/subtype (e.g., aggressive SM, SM with associated hematologic neoplasm, or mast cell leukemia) and platelet count (>50 x10^9/L).
- Prescriber specialty: oncologist.
Denial risk if diagnosis or oncologist prescriber not documented
Requests may be denied if the required diagnosis or prescriber specialty is not documented — specifically, absence of GIST with a PDGFRA mutation or absence of systemic mastocytosis documentation, or if the medication was not prescribed by an oncologist.
- Missing PDGFRA mutation for GIST or missing D842V/mutation documentation where required for SM.
- Missing documentation of systemic mastocytosis subtype or platelet count >50 x10^9/L.
- Prescriber not identified as an oncologist.
Laboratory and Diagnostic Thresholds
Key Definitions
Background
Ayvakit (avapritinib) is managed under this prior authorization guideline as a tyrosine kinase inhibitor for molecularly defined indications. Coverage is specified for gastrointestinal stromal tumor (GIST) with a PDGFRA mutation and for systemic mastocytosis (including aggressive SM, SM with associated hematologic neoplasm, and mast cell leukemia) with a D842V mutation. Initial approvals require the drug to be prescribed by an oncologist and carry an initial approval length of 3 months. For systemic mastocytosis an additional laboratory requirement is a platelet count of greater than 50 x10^9/L. Reauthorization criteria depend on duration and stability on therapy and require documentation of tumor response for continued approval.
Prior Therapy Considerations
| Step | Requirement | Notes |
|---|---|---|
| 1 | Consider history of prior tyrosine kinase inhibitor (TKI) exposure (e.g., imatinib) | Prior TKI treatment is listed as a consideration for some patients with GIST; documentation of prior therapy may be relevant to initial authorization |
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.