Medicare AdvantagePrior AuthMedium impact
Ayvakit (avapritinib) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Sep 15, 2026
Summary
Humana Medicare Advantage updated the Ayvakit (avapritinib) prior authorization policy, effective January 1, 2026, with a revision dated March 25, 2026. The policy covers three indications: PDGFRA exon 18 mutation-positive gastrointestinal stromal tumor (GIST), indolent systemic mastocytosis (ISM), and advanced systemic mastocytosis (AdvSM). All approvals require prior authorization with monotherapy use, platelet count monitoring (>50 X 10⁹/L for ISM and AdvSM), and disease progression exclusions, with 6-month initial and renewal approval durations.
Action Required
By January 1, 2026: Billing and clinical teams must implement prior authorization requirements for all Ayvakit (avapritinib) claims across three indications: (1) PDGFRA exon 18 mutation-positive unresectable/metastatic GIST with monotherapy use; (2) Indolent Systemic Mastocytosis with platelet counts >50 X 10⁹/L and monotherapy use; and (3) Advanced Systemic Mastocytosis with platelet counts >50 X 10⁹/L and monotherapy use. Update the authorization system to flag any claims with disease progression as exclusions (approval may not be appropriate). Configure approval tracking for 6-month initial and 6-month renewal periods. Providers must verify monotherapy status and obtain baseline/current platelet counts before submission. All renewals after the initial 6-month period require reauthorization. Claims submitted without completed prior authorization or that include combination therapy, platelet counts <50 X 10⁹/L, or documented disease progression will be denied. Note: The policy effective date is January 1, 2026, but this revision was published March 25, 2026—verify current version on Humana's website before processing claims.