CurrentCignaPolicy N/A

INSTRUCTIONS FOR USE

Defines quantity limits, exceptions, and approval criteria for Qinlock (ripretinib 50 mg tablets) for Cigna-administered health benefit plans, including retail and home delivery maximums and exception rules allowing larger dispenses under specific clinical circumstances.

Policy Summary

PayerCigna

PolicyINSTRUCTIONS FOR USE

Policy CodePolicy N/A

Change TypeAdded override; clarified quantity limits

Effective Date

Next Review Date

Key ActionIf the Drug Quantity Management rule is not met at point of service, coverage will be determined by the listed exception criteria; approvals are provided for 1 year.

SourceLink

POLICY UPDATE CHANGES

New override added for patients with gastrointestinal stromal tumor who experienced disease progression with Qinlock 150 mg once daily to approve 180 tablets per dispensing at retail or 540 tablets per dispensing at home delivery.

Policy updated to reflect the existing quantity limits when a product is obtained via home delivery.

90Retail Max Tablets (standard)

270Home Delivery Max Tablets (standard)

180/540Retail/Home Delivery Max (exception)

Coverage Summary

Defines quantity limits, exceptions, and approval criteria for Qinlock (ripretinib 50 mg tablets) for Cigna-administered health benefit plans. Standard maximums are 90 tablets per Rx (retail) and 270 tablets per Rx (home delivery). Exceptions allow larger dispenses when criteria are met: approve 180 tablets per dispensing (retail) or 540 tablets per dispensing (home delivery) for patients taking a moderate CYP3A inducer or for patients with gastrointestinal stromal tumor who experienced disease progression on Qinlock 150 mg once daily.

Quantity Limits

Retail Maximum Quantity per Rx (standard)90 tablets

Retail Maximum Quantity per Rx (exception)180 tablets — approve when patient is taking a moderate CYP3A inducer or has GIST with progression on Qinlock 150 mg QD

Home Delivery Maximum Quantity per Rx (standard)270 tablets

Home Delivery Maximum Quantity per Rx (exception)540 tablets — approve when patient is taking a moderate CYP3A inducer or has GIST with progression on Qinlock 150 mg QD

Drug Quantity Limit Exceptions (Medically Necessary)

Exceptions to the standard quantity limits are covered as medically necessary when ANY of the following are met:

ANY of the following

Patient is taking a moderate cytochrome P450 (CYP)3A inducer.
If met, approve 180 tablets per dispensing at retail or 540 tablets per dispensing at home delivery.
Patient has a gastrointestinal stromal tumor and has experienced disease progression with Qinlock 150 mg once daily.
If met, approve 180 tablets per dispensing at retail or 540 tablets per dispensing at home delivery.

Provider Actions & Requirements

Prior Authorization

Quantity limit override requires criteria

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the listed exception criteria; approvals are provided for 1 year.

Documentation Required

Document CYP3A inducer use

Document concomitant use of a moderate CYP3A inducer to support approval for increased quantity.

bosentan
efavirenz
etravirine
phenobarbital
primidone

Documentation Required

Document disease progression on Qinlock 150 mg QD

Document that the patient has gastrointestinal stromal tumor and experienced disease progression while on Qinlock 150 mg once daily to support approval for increased quantity.

Clinical Evidence

Prescribing information: Qinlock tablets prescribing information, Deciphera; October 2023.

Guideline: NCCN Gastrointestinal Stromal Tumor (GIST) and Melanoma guidelines (versions cited from 2025) discuss Qinlock recommendations, including dosing and sequencing; see NCCN GIST and Melanoma guidelines (2025).

Background

Qinlock is indicated for adult patients with advanced gastrointestinal stromal tumor who have received prior treatment with three or more kinase inhibitors, including imatinib.

The recommended dosing is 150 mg once daily with or without food until disease progression or unacceptable toxicity. Tablets must be swallowed whole. A dose reduction to 100 mg QD may be needed to manage adverse events. Patients should avoid coadministration with moderate or severe CYP3A inducers; if coadministration with a moderate CYP3A inducer cannot be avoided, increase dosing to 150 mg twice daily (BID). After the inducer is discontinued for at least 14 days, the prior dose may be resumed.

Moderate CYP3A inducer: examples include, but are not limited to, bosentan, efavirenz, etravirine, phenobarbital, and primidone.

Revision History

2025-05-02material_changeLatest

New override added: patients with gastrointestinal stromal tumor who experienced disease progression with Qinlock 150 mg once daily are eligible to approve 180 tablets per dispensing at retail or 540 tablets per dispensing at home delivery.

05/17/2023clarified