Coverage Policies

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QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.


Effective Date: 06/01/2020 Title: Ayvakit
Revision Date: Document: BI654:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Ayvakit (avapritinib) requires prior authorization.

2)    Ayvakit is used to treat gastrointestinal stromal tumors (GIST).

3)    Ayvakit is an oral specialty drug and must be obtained through a contracted specialty pharmacy.

Medical Statement

Ayvakit (avapritinib) is considered medically necessary for members 18 years of age and older who meet the following criteria:


1)    Diagnosis of unresectable or metastatic GIST AND

2)    Prescribed by or in consultation with an oncologist AND

3)    One of the following (a or b):

a.    Documentation of PDGFRA exon 18 D842V mutation:

b.    Member meets both of the following:

                                          i.    Documentation of PDGFRA exon 18 mutation other than D842V;

                                        ii.    Failure of imatinib, unless contraindicated or clinically significant adverse effects are experienced;

4)    Dose does not exceed 300mg (1 tablets) per day.


Reauthorization is approved if documented that member is responding positively to drug and dose does not exceed 300mg per day.


As an oral specialty drug, Ayvakit is limited to a maximum 30-day supply per fill.


1)    Ayvakit Prescribing Information. Cambridge, MA: Bluepring Medicines Corporation; January 2020.

2)    NCCN Drugs & Biologics Compendium. Accessed online 4/30/20.

3)    Clinical Pharmacology. Accessed online 4/30/20.

4)    Heinrich M, Jones RL, Mehren M, et al. A hase 1 study of BLU-285 in patients with gastrointestinal stromal tumors (GIST) andotherrelapsed and refractory solid tumors (NAVIGATOR). (2019). Retrieved from (Identification No. NCT02508532)

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.