By Counterforce Health Team in Qinlock (ripretinib) —

Requirements Checklist to Get Qinlock (ripretinib) Covered by Aetna CVS Health in Virginia

Answer Box: Getting Qinlock (ripretinib) Covered by Aetna CVS Health in Virginia

Eligibility: Qinlock requires prior authorization from Aetna CVS Health for fourth-line GIST treatment after documented failure of imatinib, sunitinib, and regorafenib. Fastest path: Submit complete documentation including pathology report, treatment history with outcomes, and medical necessity letter through CVS Specialty or Aetna provider portal. First step today: Call 1-866-638-1232 to verify formulary status and obtain PA forms. If denied, Virginia offers external review through the State Corporation Commission Bureau of Insurance within 120 days.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Information
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: Tracking Your Request
  9. Denial Prevention Tips
  10. Appeals Process in Virginia
  11. Printable Checklist

Who Should Use This Checklist

This comprehensive checklist is designed for patients diagnosed with advanced gastrointestinal stromal tumor (GIST) and their healthcare teams seeking Aetna CVS Health coverage for Qinlock (ripretinib) in Virginia. You'll need this guide if:

  • Your oncologist has prescribed Qinlock as fourth-line therapy after progression on at least three prior kinase inhibitors
  • You've received a denial from Aetna CVS Health for Qinlock coverage
  • You're preparing a prior authorization request to avoid initial denial
  • You need to understand Virginia-specific appeal rights and external review processes

Expected outcome: Following this checklist increases your chances of approval by ensuring all Aetna CVS Health requirements are met upfront, potentially saving 2-4 weeks compared to incomplete submissions that trigger additional information requests.

Member & Plan Basics

Verify Active Coverage

Before starting your prior authorization request, confirm these essential details:

Coverage Verification Checklist:

  • Active Aetna CVS Health membership (call 1-866-638-1232)
  • Prescription drug benefits included in your plan
  • Current deductible status and out-of-pocket maximums
  • Specialty pharmacy requirements (typically CVS Specialty mandatory)

Plan Type Considerations

Aetna CVS Health formulary placement varies by plan type:

Plan Type Typical Qinlock Status Prior Auth Required
Advanced Control Plan Non-preferred (Tier 5) Yes
Standard Plan Non-formulary or Tier 5 Yes
Medicare Part D Specialty tier Yes
Note: Formulary status can change quarterly. Always verify current placement through the member portal or by calling member services.

Clinical Criteria Requirements

FDA-Approved Indication

Qinlock is approved for adult patients with advanced GIST who have received prior treatment with three or more kinase inhibitors, including imatinib. Your documentation must demonstrate:

Required Clinical Elements:

  • Confirmed GIST diagnosis with pathology report showing CD117 (KIT) and/or DOG1 positivity
  • ICD-10 diagnosis code (typically C49.A2 for gastric GIST)
  • Advanced/metastatic disease status confirmed by imaging

Step Therapy Documentation

Aetna CVS Health requires documented failure, intolerance, or contraindication to at least three prior kinase inhibitors:

Mandatory Prior Therapies:

  1. Imatinib (first-line): Minimum 3 months at 400-800mg daily with documented progression or intolerance
  2. Sunitinib (second-line): Minimum 2 cycles at 50mg daily (4 weeks on, 2 weeks off) with progression or intolerance
  3. Regorafenib (third-line): Minimum 2 cycles at 160mg daily with progression or intolerance
Tip: Treatment failures from any healthcare system count toward step therapy requirements. Gather records from all previous oncologists.

Dosing and Duration

Document the prescribed regimen aligns with FDA labeling:

  • Starting dose: 150mg once daily
  • Duration: Until disease progression or unacceptable toxicity
  • Dose modification plan for adverse events documented

Coding and Billing Information

Diagnosis Codes

Use appropriate ICD-10 codes based on GIST location:

GIST Location Primary ICD-10 Code Secondary Codes (if applicable)
Stomach C49.A2 Z51.11 (encounter for chemotherapy)
Small intestine C49.4 Z87.03 (history of malignant neoplasm)
Other GI tract C49.A9 Z51.12 (encounter for immunotherapy)

Drug Coding

  • NDC Number: 83211-310-01 (150mg tablets, 30-count bottle)
  • HCPCS Code: J8999 (prescription drug, oral, chemotherapeutic, NOS) if required
  • Billing: Typically through pharmacy benefit; verify with member services

Documentation Packet

Provider Medical Necessity Letter

Your oncologist's letter must address these specific elements:

Essential Letter Components:

  • Patient demographics and Aetna member ID
  • Detailed GIST diagnosis with pathology confirmation
  • Complete prior treatment history with dates, doses, and outcomes
  • Clinical rationale citing NCCN guidelines for fourth-line therapy
  • Treatment goals and monitoring plan
  • Physician credentials and signature

Counterforce Health specializes in helping patients and clinicians create targeted, evidence-backed appeals for insurance denials. Their platform can help identify the specific denial basis and draft point-by-point rebuttals aligned to Aetna's coverage criteria.

Required Attachments

Compile these supporting documents:

Clinical Documentation:

  • Pathology report confirming GIST diagnosis
  • Recent imaging showing disease progression
  • Complete treatment timeline from all prior oncologists
  • Laboratory results (CBC, comprehensive metabolic panel, liver function)
  • Performance status assessment (ECOG or Karnofsky scale)

Administrative Forms:

  • Completed prior authorization form
  • CVS Specialty enrollment form
  • Insurance card copy (front and back)

Submission Process

Correct Form Version

Obtain the most current prior authorization form:

  • Primary method: Aetna provider portal (Availity)
  • Alternative: Fax request to 1-866-249-6155
  • Phone: Provider services at 1-866-785-5714

Submission Options

Choose your preferred submission method:

Method Timeline Best For
Electronic (Availity portal) 5-14 business days Complete submissions
CoverMyMeds ePA 5-14 business days Integrated EHR systems
Fax: 1-866-249-6155 15 business days Paper documentation
Important: Always request and record confirmation numbers for tracking purposes.

Required Fields That Commonly Cause Rejections

Double-check these frequently missed elements:

  • Complete member ID (not just last 4 digits)
  • Prescriber NPI number and DEA registration
  • Exact drug name, strength, and NDC
  • Specific ICD-10 codes (not just "cancer")
  • Prior authorization number if resubmission

Specialty Pharmacy Requirements

CVS Specialty Enrollment

Aetna CVS Health typically requires dispensing through CVS Specialty:

Enrollment Process:

  1. Patient enrollment: Call 1-800-237-2767 or complete online form
  2. Prescriber enrollment: Fax prescription to 1-800-323-2445
  3. Insurance verification: CVS Specialty coordinates with Aetna
  4. Shipment setup: Cold-chain delivery arranged (typically 2-3 day shipping)

Transfer from Retail Pharmacy

If currently using retail pharmacy:

  • Request prescription transfer to CVS Specialty
  • Verify remaining refills transfer completely
  • Confirm delivery address and preferred shipping days
  • Set up automatic refill if desired

After Submission: Tracking Your Request

Confirmation and Status Checks

Document these details immediately after submission:

  • Confirmation number or reference ID
  • Submission date and method
  • Expected decision timeline (typically 15 business days)
  • Case manager contact information (if assigned)

Status Check Schedule

Monitor your request progress:

  • Day 3-5: Verify receipt and completeness
  • Day 10: Check for additional information requests
  • Day 15: Decision should be rendered
  • Day 20: Follow up if no decision received
Tip: Set calendar reminders for each checkpoint to avoid delays.

Denial Prevention Tips

Five Common Pitfalls and How to Avoid Them

1. Incomplete Step Therapy Documentation

  • Pitfall: Listing prior medications without specific dates, doses, and outcomes
  • Fix: Create detailed treatment timeline with progression imaging dates

2. Missing Pathology Confirmation

  • Pitfall: Assuming GIST diagnosis is obvious from clinical presentation
  • Fix: Include original pathology report with CD117/DOG1 immunohistochemistry results

3. Inadequate Medical Necessity Justification

  • Pitfall: Generic letter not addressing Aetna's specific coverage criteria
  • Fix: Reference Aetna Clinical Policy Bulletin requirements point-by-point

4. Wrong Submission Route

  • Pitfall: Submitting to medical benefit when drug requires pharmacy prior auth
  • Fix: Verify benefit coverage (medical vs. pharmacy) before submission

5. Expired or Incorrect Forms

  • Pitfall: Using outdated prior authorization forms from previous years
  • Fix: Download current forms from Aetna provider portal each time

Appeals Process in Virginia

Internal Appeals with Aetna CVS Health

If your initial request is denied:

Level 1 Appeal (Standard):

  • Timeline: File within 180 days of denial notice
  • Method: Written appeal via member portal or mail
  • Decision time: 30 days for non-urgent, 72 hours for urgent
  • Required: Copy of denial letter, additional clinical documentation

Peer-to-Peer Review:

  • Request physician-to-physician discussion
  • Available for medical necessity denials
  • Schedule through provider services: 1-866-785-5714

Virginia External Review Process

After exhausting internal appeals, Virginia residents can request external review through the State Corporation Commission Bureau of Insurance:

External Review Requirements:

  • File within 120 days of final internal denial
  • Complete Form 216-A (External Review Request)
  • Include written explanation of coverage violation
  • Submit to: Virginia Bureau of Insurance, Life & Health Consumer Services

Timeline for External Review:

  • Standard review: 45 days maximum
  • Expedited review: 72 hours for urgent medical necessity
  • Decision: Binding on Aetna CVS Health

For assistance with Virginia external review, contact the Bureau of Insurance at 1-877-310-6560 or visit their external review page.

Printable Checklist

Pre-Submission Checklist

Print this section and check off each item before submitting:

Patient Information:

  • Active Aetna CVS Health coverage verified
  • Member ID and policy information confirmed
  • Specialty pharmacy enrollment initiated

Clinical Documentation:

  • GIST pathology report with CD117/DOG1 results
  • Three prior kinase inhibitor failures documented with dates/outcomes
  • Recent imaging showing progression
  • Current laboratory results within 30 days

Provider Requirements:

  • Medical necessity letter addressing Aetna criteria
  • Prescription with correct NDC and dosing
  • Provider NPI and DEA numbers included

Submission Details:

  • Current prior authorization form completed
  • All required attachments included
  • Submission method selected and confirmation number obtained
  • Follow-up schedule established

From our advocates: "We've seen many Qinlock approvals in Virginia when patients work closely with their oncology team to document the complete treatment journey. The key is showing clear progression through each line of therapy with specific dates and imaging. Don't assume the reviewer knows your case – spell out why Qinlock is the appropriate next step based on your individual treatment history."

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed documentation that addresses specific payer requirements. Their platform can help identify denial patterns and draft responses that align with Aetna's coverage policies.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance company for personalized guidance. For official Virginia insurance regulations and consumer rights, visit the State Corporation Commission Bureau of Insurance.

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