By Counterforce Health Team in Qinlock (ripretinib) —

Qinlock (Ripretinib) Approval with Humana in Virginia: Answers to the Most Common Questions

Answer Box: Getting Qinlock Covered by Humana in Virginia

Qinlock (ripretinib) requires prior authorization from Humana with documented failure of three prior kinase inhibitors: imatinib, sunitinib, and regorafenib. Submit PA via Humana's provider portal with complete treatment history, pathology confirming advanced GIST, and imaging showing disease progression. Standard approval takes 7 days for Part D; expedited review available for urgent cases within 72 hours. If denied, Virginia residents have 65 days to appeal internally, then can request external review via Form 216-A through the State Corporation Commission.

First step today: Have your oncologist gather records of all prior TKI therapies and submit the PA request through Humana's provider portal.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Step Therapy Criteria
  5. Costs and Copays
  6. Denials and Appeals
  7. Renewal Requirements
  8. Specialty Pharmacy
  9. Troubleshooting
  10. Glossary

Coverage Basics

Is Qinlock (ripretinib) covered by Humana?

Yes, Qinlock is covered on Humana Medicare Part D formularies as a specialty tier 5 medication. Coverage requires prior authorization and step therapy documentation showing failure of at least three prior kinase inhibitors. The drug is FDA-approved for fourth-line treatment of advanced gastrointestinal stromal tumors (GIST) and costs approximately $43,000-$48,000 per month.

Which Humana plans cover it?

  • Medicare Advantage with Part D (MAPD)
  • Stand-alone Part D plans
  • Enhanced PDP plans

Check your specific formulary at Humana's drug list tool or call the number on your member ID card.

Prior Authorization Process

Who submits the prior authorization?

Your oncologist or their staff submits the PA request. Patients cannot submit directly. The clinic typically uses Humana's electronic provider portal or fax system.

Required Documentation Checklist

  • Completed Humana PA form
  • Pathology report confirming GIST diagnosis
  • Treatment timeline showing dates and outcomes of:
    • Imatinib therapy (typically 3-6 months)
    • Sunitinib therapy
    • Regorafenib therapy
  • Imaging reports documenting disease progression
  • Medical necessity letter from oncologist
  • Current performance status assessment
Tip: Request all prior treatment records from previous oncologists before starting the PA process. Missing documentation is the most common reason for delays.

Timing and Urgency

How long does standard approval take?

  • Part D medications: 7 calendar days for standard review
  • Expedited review: 72 hours when medically urgent
  • Electronic submissions: Often processed within 1-2 business days

When can I request expedited review?

Request expedited review if delaying Qinlock would:

  • Seriously jeopardize your life or health
  • Significantly impair your ability to regain function
  • Subject you to severe pain that cannot be managed adequately

Your oncologist must support the urgency request with clinical documentation.

Step Therapy Criteria

What counts as adequate prior therapy failure?

Humana requires documented progression or intolerance to all three of these medications in sequence:

Line of Therapy Medication Typical Duration Documentation Required
First-line Imatinib (Gleevec) 3-6 months at maximum tolerated dose Imaging showing progression or toxicity notes
Second-line Sunitinib (Sutent) Standard dosing per label Clinic notes with progression dates
Third-line Regorafenib (Stivarga) Standard dosing per label Radiologic progression evidence

Can step therapy be bypassed?

Rarely. Exceptions may be granted if:

  • Patient has documented contraindications to required prior therapies
  • Severe allergic reactions to required medications occurred
  • Specific genetic mutations make alternative sequencing appropriate

Costs and Copays

What will I pay for Qinlock?

Medicare Part D specialty tier 5 typically requires 25-33% coinsurance after meeting your deductible. Exact costs depend on your specific plan and whether you've reached catastrophic coverage.

Cost assistance options:

  • Deciphera AccessPoint: Manufacturer patient assistance program
  • Foundation grants: PAN Foundation, others (for Medicare patients)
  • Tier exception requests: May lower copay if alternatives inappropriate
Note: Medicare patients cannot use traditional copay cards, but foundation grants may help with out-of-pocket costs.

Denials and Appeals

Common denial reasons and solutions:

Denial Reason How to Fix
"Insufficient prior therapy documentation" Submit complete records with dates, doses, and progression evidence
"Step therapy not met" Provide imaging reports showing failure of all three required TKIs
"Not medically necessary" Include NCCN guidelines and FDA label supporting fourth-line use
"Quantity limits exceeded" Verify prescription is for standard 150mg daily dose

Virginia Appeal Process

Internal Appeal (First Step):

  • File within 65 days of denial notice
  • Submit via Humana member portal or mail
  • Include additional documentation addressing denial reasons

External Review (Second Step):

  • Available after exhausting Humana's internal process
  • Use Form 216-A through Virginia State Corporation Commission
  • File within 120 days of final internal denial
  • Free process with independent medical review

Contact the Virginia Managed Care Ombudsman at 1-877-310-6560 for assistance with appeals.

Renewal Requirements

When do I need to renew authorization?

Most Humana PA approvals for Qinlock are granted for 12 months with automatic refill authorization. Your oncologist may need to submit:

  • Updated clinical notes showing continued benefit
  • Recent imaging confirming stable or responding disease
  • Confirmation that treatment remains appropriate

What changes might affect coverage?

  • Plan formulary updates (rare for ongoing therapy)
  • New clinical guidelines
  • Alternative treatments becoming available
  • Changes in FDA labeling

Specialty Pharmacy

Why was my prescription transferred?

Qinlock requires specialty pharmacy dispensing due to:

  • High cost requiring enhanced monitoring
  • Need for patient education and adherence support
  • Special handling and storage requirements

Humana's preferred specialty pharmacies:

  • Accredo Specialty Pharmacy
  • CVS Specialty
  • Express Scripts Specialty

Your prescription will automatically be transferred to one of these networks.

Troubleshooting

Portal issues:

Provider portal down? Fax PA requests to 877-486-2621 (verify current fax number with Humana).

Missing forms? Download current PA forms from Humana's provider resources.

Communication problems:

No response after 7 days? Call Humana Provider Services to check PA status and request expedited review if appropriate.

Conflicting information? Request peer-to-peer review with Humana's medical director.

From Our Advocates

We've seen many Virginia patients successfully obtain Qinlock coverage after initial denials by working closely with their oncology team to compile comprehensive treatment histories. The key is often providing detailed imaging reports that clearly document progression on each prior therapy, along with a strong medical necessity letter referencing NCCN guidelines. Most appeals succeed when the documentation clearly shows the sequential failure of imatinib, sunitinib, and regorafenib.

Glossary

Prior Authorization (PA): Insurance requirement to approve coverage before dispensing expensive medications.

Step Therapy: Requirement to try preferred medications before covering alternatives.

Medical Necessity: Clinical justification that a treatment is appropriate and required.

Peer-to-Peer (P2P): Direct conversation between prescribing physician and insurance medical director.

Formulary: List of medications covered by an insurance plan.

Quantity Limit (QL): Restriction on amount of medication dispensed per time period.

External Review: Independent medical review by third-party organization after internal appeals are exhausted.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients needing specialty medications like Qinlock. Our platform helps clinicians prepare evidence-backed prior authorization requests and appeals by analyzing denial letters, identifying specific coverage criteria, and drafting targeted rebuttals aligned with each payer's requirements. We understand that navigating complex prior authorization processes can be overwhelming, especially when dealing with serious conditions like GIST, which is why we focus on streamlining the approval process for both patients and healthcare providers.

For Virginia residents facing Humana denials, working with experienced advocacy services like Counterforce Health can significantly improve approval rates by ensuring all documentation meets Humana's specific requirements and appeals address the exact reasons for denial.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For assistance with Virginia insurance issues, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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