By Counterforce Health Team in Vanflyta (quizartinib) —

Get Vanflyta (Quizartinib) Covered by Aetna CVS Health in New Jersey: Complete Forms & Appeals Guide

Answer Box: Getting Vanflyta (Quizartinib) Covered by Aetna CVS Health in New Jersey

Vanflyta (quizartinib) requires prior authorization from Aetna CVS Health for all New Jersey members. The fastest approval path involves: 1) Submit PA through CVS Caremark Provider Portal with FLT3-ITD test results and baseline EKG (24-48 hours), 2) If denied, file internal appeal with medical necessity letter within 180 days, 3) Use New Jersey's IHCAP external review through Maximus if internal appeals fail. Start today by verifying your plan's formulary status and gathering required clinical documentation.

Table of Contents

Start Here: Verify Your Plan

Before starting the prior authorization process, confirm your specific Aetna CVS Health plan details. Vanflyta coverage varies by plan type, and requirements can differ between commercial, Medicare Advantage, and Medicaid managed care plans.

What to verify:

  • Call the member services number on your Aetna ID card
  • Ask specifically about Vanflyta (quizartinib) formulary status
  • Confirm if step therapy requirements apply
  • Check if CVS Specialty Pharmacy is required
Note: In northern New Jersey, some Aetna members may need to use EviCore for certain preauthorizations. Always check your member ID card for specific instructions.

Prior Authorization Forms & Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required for all Aetna plans CVS Caremark Provider Portal 24-48 hours (electronic)
FLT3-ITD Testing Must show positive mutation PCR-based assay results Required before submission
Baseline EKG QTc ≤450 ms documented Cardiology or oncology notes Within 30 days of request
Diagnosis Code ICD-10 C92.00 (AML) Medical records Current episode
Treatment Phase Induction/consolidation/maintenance Oncologist documentation Specify intended use

Required Clinical Documentation

For all Vanflyta prior authorization requests, you'll need:

  1. FLT3-ITD Mutation Confirmation
    • PCR-based assay showing positive FLT3-ITD status
    • FDA-approved test results required
    • Must be from current AML diagnosis
  2. Cardiac Safety Documentation
    • Baseline EKG with QTc ≤450 ms
    • Electrolyte panel (if corrections were needed)
    • Plan for ongoing cardiac monitoring
  3. Treatment Context
    • AML diagnosis with ICD-10 code C92.00
    • Intended treatment phase (induction, consolidation, or maintenance)
    • Note: Not approved for use after allogeneic stem cell transplant
  4. Prescriber Information
    • Oncologist or hematologist NPI number
    • Practice address and contact information
    • DEA number for controlled substance prescribing

Submission Portals & Methods

Fastest Electronic Options

CVS Caremark Provider Portal (Recommended)

  • Processing time: 24-48 hours
  • Direct document upload capability
  • Real-time status tracking
  • Registration required at caremark.com

CoverMyMeds Integration

  • Works with most EHR systems
  • Automated form population
  • Same 24-48 hour timeline
  • No separate portal registration needed

Direct EHR Integration

  • Surescripts connectivity
  • Epic, Cerner, and other major systems
  • Seamless workflow for providers
  • Fastest option when available

Traditional Submission Methods

Fax Submission

  • Processing time: 2-3 business days
  • Fax number: Verify current number through provider portal
  • Include all supporting documents
  • Use clear cover sheet with member ID
Tip: Always confirm current fax numbers through the official CVS Caremark provider resources, as these can change without notice.

Specialty Pharmacy Setup

CVS Specialty Pharmacy is typically required for Vanflyta dispensing under Aetna CVS Health plans. The enrollment process runs parallel to prior authorization.

Step-by-Step Enrollment

  1. Provider Initiates Transfer
    • Contact CVS Specialty at 1-866-782-2779
    • Provide original prescription details
    • Complete oncology enrollment form
  2. Benefits Investigation
    • CVS Specialty verifies insurance coverage
    • Identifies copay amounts and deductibles
    • Coordinates with prior authorization process
  3. Patient Assistance Screening
    • Automatic screening for manufacturer programs
    • Copay card application if eligible
    • Foundation grant research for qualifying patients
  4. Delivery Coordination
    • Secure packaging for temperature control
    • Signature required delivery
    • Typically within 48 hours of approval
From our advocates: "We've seen patients save significant time by starting the specialty pharmacy enrollment simultaneously with the PA submission. CVS Specialty can often have everything ready to ship within hours of approval, rather than adding another week to the process."

Appeals Process for Denials

If your initial prior authorization is denied, New Jersey provides strong appeal rights through both internal Aetna processes and external review.

Common Denial Reasons & Solutions

Denial Reason Required Documentation How to Address
No FLT3-ITD documentation Mutation test results Submit PCR assay showing positive FLT3-ITD
Cardiac monitoring concerns EKG and monitoring plan Provide baseline EKG ≤450ms + ongoing plan
Step therapy required Prior treatment records Document failures/intolerance to preferred agents
Non-formulary status Medical necessity letter Request formulary exception with clinical rationale

Internal Appeals Timeline

Level 1 Appeal

  • Deadline: 180 days from denial
  • Processing: 30 days (standard), 72 hours (expedited)
  • Submit via: Member portal or written request
  • Required: Medical necessity letter from oncologist

Level 2 Appeal (if applicable)

  • Automatic in some Aetna plans
  • Same timeline as Level 1
  • Independent medical reviewer
  • Peer-to-peer review option available

Medical Necessity Letter Checklist

Your oncologist's appeal letter should address:

  • Patient's specific AML subtype with FLT3-ITD mutation status
  • Prior treatment failures or contraindications to preferred alternatives
  • Clinical rationale for Vanflyta in this treatment phase
  • Monitoring plan for cardiac safety and efficacy
  • Guideline support from NCCN or other recognized sources

New Jersey External Review (IHCAP)

New Jersey's Independent Health Care Appeals Program (IHCAP) provides binding external review of insurance denials, administered by Maximus Federal Services.

When to Use External Review

  • Internal appeals with Aetna have been completed or waived
  • Denial is based on medical necessity determination
  • You're within 180 days of final internal denial
  • Your plan is New Jersey-regulated (not self-funded employer plans)

IHCAP Process Steps

  1. Submit Application
  2. Preliminary Review
    • Maximus determines eligibility within 5 business days
    • May request additional documentation
    • Confirms internal appeals were completed
  3. Independent Medical Review
    • Specialist physicians review case
    • Consider medical records and current guidelines
    • Decision within 45 days (standard) or 72 hours (expedited)
  4. Binding Decision
    • If overturned, Aetna must provide coverage
    • Success rate: Approximately 68% for oncology drugs
    • Final and enforceable under New Jersey law

Contact Information:

  • IHCAP Hotline: 1-888-393-1062
  • Email: [email protected]
  • NJ DOBI Consumer Hotline: 1-800-446-7467

Support Contact Directory

Aetna Member Services

  • General Member Services: Number on your ID card
  • Specialty Pharmacy Support: 1-866-782-2779 (TTY: 711)
  • Hours: 8 AM - 8 PM ET, Monday-Friday

Provider Support

  • CVS Caremark Provider Help: Available through provider portal
  • Precertification Phone: 1-866-503-0857
  • Precertification Fax: 1-866-267-3277

Emergency & Urgent Situations

  • Expedited Appeals: Call member services immediately
  • Clinical Emergencies: Contact your oncologist first
  • Pharmacy Emergencies: 1-866-782-2779 for urgent refills

Cost Assistance Programs

Vanflyta's cash price ranges from approximately $16,100-$17,900 per 28-day supply, making assistance programs crucial for many patients.

Manufacturer Support

  • Daiichi Sankyo Patient Assistance: Check VanflytaHCP.com for current programs
  • Eligibility: Typically based on income and insurance status
  • Application: Through specialty pharmacy or directly with manufacturer

Copay Assistance

  • Commercial Insurance: Copay cards may be available
  • Income Limits: Usually apply for assistance programs
  • Medicare Patients: Limited options due to federal restrictions

Foundation Grants

  • Cancer-Specific Foundations: Multiple organizations provide grants
  • Application Process: CVS Specialty typically assists with applications
  • Eligibility: Based on diagnosis, income, and insurance coverage

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with your insurer's own rules, significantly improving approval rates for complex specialty medications like Vanflyta.

FAQ

How long does Aetna CVS Health prior authorization take for Vanflyta in New Jersey? Electronic submissions through the CVS Caremark Provider Portal typically receive decisions within 24-48 hours. Fax submissions take 2-3 business days.

What if Vanflyta is non-formulary on my plan? Request a formulary exception by submitting a medical necessity letter documenting why Vanflyta is clinically appropriate and preferred alternatives are unsuitable.

Can I request an expedited appeal if my treatment is urgent? Yes. Contact Aetna member services immediately to request expedited review, which must be completed within 72 hours for urgent situations.

Does step therapy apply to FLT3 inhibitors in New Jersey? Step therapy requirements vary by plan. Some Aetna plans may require trial of midostaurin (Rydapt) before approving Vanflyta, while others may not have step therapy for this drug class.

What happens if I move to New Jersey from another state during treatment? Contact Aetna member services immediately to update your address and confirm continued coverage. New Jersey's external appeal rights will apply to future denials.

How do I know if my employer plan is subject to New Jersey regulations? Self-funded employer plans follow federal ERISA rules, not state regulations. Check with your HR department or look for "self-funded" language in your plan documents.

Sources & Further Reading

For personalized guidance on navigating complex prior authorization and appeal processes, Counterforce Health provides expert assistance in transforming insurance denials into successful approvals through evidence-based appeals tailored to each payer's specific requirements.

This guide provides educational information and should not replace professional medical or legal advice. Always consult with your healthcare provider and insurance plan directly for medical decisions and coverage questions. Information is current as of publication but may change. Verify all contact information and requirements with official sources.

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