Pharmacy Prior Authorization Criteria

Qinlock (ripretinib)

Indications for Prior Authorization

Qinlock (ripretinib)

• For diagnosis of Gastrointestinal Stromal Tumor (GIST)
  Indicated for the treatment of adult patients with advanced gastrointestinal stromal tumor (GIST) who have received prior treatment with 3 or more kinase inhibitors, including imatinib.

Criteria

Qinlock

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of gastrointestinal stromal tumor (GIST)
AND
• Disease is advanced
AND
• Patient has received prior treatment with three or more kinase inhibitors (e.g., sunitinib, regorafenib), one of which must include imatinib

Qinlock

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2024-07-18, 2023-07-05, 2022-07-22, 2021-07-07, 2021-05-21, 2021-04-09, 2020-06-30

References

1. Qinlock Prescribing Information. Deciphera Pharmaceuticals, LLC. Waltham, MA. October 2023.

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Revision History

• 2024-07-18: 2024 annual review: no criteria changes.
• 2023-07-05: Annual review - removed specialist requirement.
• 2022-07-22: Annual review: no criteria changes, updated reference.
• 2021-07-07: Annual review: Background updates. No criteria changes.
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2021-04-09: Updated GPIs
• 2020-06-30: New program

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