By Counterforce Health Team in Vanflyta (quizartinib) —

How to Get Vanflyta (Quizartinib) Covered by Aetna CVS Health in Georgia: Complete Forms, Appeals, and Approval Guide

Answer Box: Getting Vanflyta Covered by Aetna CVS Health in Georgia

Vanflyta (quizartinib) requires prior authorization from Aetna CVS Health for FLT3-ITD positive AML. Your fastest path to approval: (1) Confirm FLT3-ITD mutation testing with PCR-based assay, (2) Obtain baseline EKG showing QTc ≤450ms, and (3) Submit complete PA form via CVS Caremark provider portal. First step today: Call Aetna member services at 1-888-792-3862 to verify your plan's specific requirements and obtain the current PA form. If denied, you have 180 days to appeal internally, then 60 days for Georgia external review through the state Department of Insurance.

Table of Contents

Verify Your Plan Coverage

Before starting the approval process, confirm your specific Aetna CVS Health plan requirements. Vanflyta is classified as a specialty medication requiring prior authorization across all Aetna plan types in 2024, including commercial, Medicare Advantage, and Medicaid managed care plans.

What to verify:

  • Current formulary tier for Vanflyta
  • Step therapy requirements (may need to try other FLT3 inhibitors first)
  • Quantity limits and dispensing restrictions
  • Specialty pharmacy network requirements

Call Aetna member services at 1-888-792-3862 (TTY: 711) to confirm your plan's specific coverage details.

Prior Authorization Requirements

Coverage at a Glance

Requirement Details Where to Find It
PA Required Yes, for all plans Aetna 2024 Precertification List
Diagnosis FLT3-ITD positive AML (ICD-10: C92.00) FDA label, clinical records
Mutation Testing PCR-based FLT3-ITD assay required Lab report with allelic ratio
Baseline EKG QTc ≤450ms within 30 days Cardiology or oncology records
Specialty Pharmacy CVS Specialty network only CVS Specialty enrollment

Required Clinical Documentation

Essential documents for approval:

  1. FLT3-ITD mutation testing - PCR-based assay with allelic ratio included
  2. AML diagnosis confirmation - Pathology report with bone marrow biopsy results
  3. Baseline electrocardiogram - QTc interval ≤450 milliseconds within 30 days
  4. Electrolyte panel - With correction documentation if abnormalities present
  5. Treatment phase specification - Induction, consolidation, or maintenance
  6. Prescriber credentials - Hematology/oncology specialist with NPI
Tip: Missing any single required document can delay approval by weeks. Gather all documentation before submitting your PA request.

Submission Process and Forms

Electronic Submission (Fastest)

Submit your prior authorization through the CVS Caremark provider portal via Availity's Aetna Payer Spaces. Electronic submissions typically receive decisions within 24-48 hours.

Steps for providers:

  1. Log into Availity and navigate to Aetna Payer Spaces
  2. Select "Prior Authorization" for specialty medications
  3. Complete the Vanflyta-specific PA form
  4. Upload all required clinical documentation
  5. Submit with correct NDC for prescribed tablet strength

Fax and Mail Options

If electronic submission isn't available:

Fax: 1-833-596-0339 (FaxHub for precertification) Mail: PO Box 14079, Lexington, KY 40512-4079

Include a cover sheet identifying the request as "Vanflyta (quizartinib) Prior Authorization" with member ID and prescriber contact information.

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Missing FLT3-ITD documentation Submit PCR-based assay results with allelic ratio
QTc monitoring not addressed Provide baseline EKG showing QTc ≤450ms
Step therapy required Document prior FLT3 inhibitor failures/intolerance
Non-formulary status Request formulary exception with medical necessity letter
Treatment phase unclear Specify induction, consolidation, or maintenance phase

Medical Necessity Letter Checklist

When appealing or requesting exceptions, include these elements:

  • Clinical problem: FLT3-ITD positive AML diagnosis with specific mutation details
  • Prior treatments: Document previous therapies and outcomes/failures
  • Clinical rationale: Why Vanflyta is medically necessary for this patient
  • Guideline support: Reference FDA labeling and NCCN guidelines
  • Monitoring plan: QTc monitoring and cytopenia management protocols

Appeals Process in Georgia

Internal Appeals with Aetna

Timeline: File within 180 days of denial Standard review: 30-45 days for decision Expedited review: 72 hours for urgent situations

How to file:

  • Call 1-888-632-3862 for medical appeals
  • Submit additional clinical documentation
  • Request peer-to-peer review if available

Georgia External Review

If your internal appeal is denied, Georgia law provides an independent external review process.

Key deadlines:

  • 60 days from final internal denial to request external review
  • 30 days for external reviewer decision

How to request external review:

  1. Contact Georgia Department of Insurance
    • Phone: (800) 656-2298 or (404) 656-2070
    • Address: Office of Commissioner of Insurance and Fire Safety, Consumer Services Division, 2 Martin Luther King Jr. Dr., West Tower, Suite 702, Atlanta, GA 30334
  2. Required documents:
    • Completed external review request form
    • Copy of your Notice of Final Adverse Benefit Determination
  3. No cost to you - External review is free for Georgia consumers
Note: External review decisions are binding on Aetna and must be honored if the decision supports coverage.

CVS Specialty Pharmacy Enrollment

Vanflyta is dispensed exclusively through CVS Specialty Pharmacy network. The enrollment process can be expedited through their Specialty Expedite program.

Enrollment Timeline

  • Standard process: 1-3 weeks
  • Specialty Expedite: Average 3 days with EHR integration

Patient Portal Setup

  1. Create account at CVSspecialty.com
  2. Enroll in text/email updates for prescription status
  3. Access CareTeam support at 1-888-346-3731

CareTeam services include:

  • Benefits verification and PA support
  • Self-injection training for patients
  • Medication adherence monitoring
  • Insurance coordination

Support Resources and Contacts

Aetna Contact Information

Member Services: 1-888-792-3862 (TTY: 711) Provider Services: 1-888-632-3862 (medical and behavioral health) Pharmacy: 1-800-238-6279 (TTY: 711)

Georgia Consumer Assistance

Georgia Department of Insurance Consumer Services

Georgians for a Healthy Future

  • Nonprofit providing consumer assistance with appeals
  • Publishes guides on insurance appeals process

Prescription Assistance

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical citations and weaving them into appeals that meet procedural requirements while tracking deadlines.

Daiichi Sankyo Patient Support

  • Check manufacturer website for copay assistance programs
  • Verify eligibility requirements and application process

FAQ

How long does Aetna CVS Health prior authorization take for Vanflyta in Georgia? Electronic submissions through the provider portal typically receive decisions within 24-48 hours. Fax and mail submissions may take 2-3 business days for initial review.

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 why formulary alternatives are inadequate.

Can I request an expedited appeal if my situation is urgent? Yes, Aetna offers expedited appeals for urgent situations with decisions within 72 hours. Contact member services to request expedited review.

Does step therapy apply if I've tried FLT3 inhibitors outside Georgia? Prior therapy documentation from any location should satisfy step therapy requirements. Provide complete records of previous treatments and outcomes.

What happens if I miss the 60-day external review deadline in Georgia? The 60-day deadline is statutory, but contact the Georgia Department of Insurance immediately if you've missed it - they may provide guidance on exceptional circumstances.

How much does Vanflyta cost without insurance? Cash prices range from approximately $16,100-$17,900 per 28-day supply depending on strength and quantity, according to GoodRx pricing data.

Can I appeal while continuing current treatment? Yes, continue your current therapy during the appeals process. For urgent situations, request expedited review to avoid treatment delays.

What should I do if my appeal is denied? After exhausting Aetna's internal appeals, file for Georgia external review within 60 days. The external review decision is binding on Aetna.

From our advocates: "We've seen Vanflyta approvals succeed when providers include the complete FLT3 mutation testing panel with allelic ratios, not just a positive/negative result. The baseline EKG showing QTc ≤450ms is equally critical - payers consistently deny without this cardiac safety documentation. These details make the difference between approval and lengthy appeals."

When navigating insurance coverage for specialty medications like Vanflyta, having the right documentation and understanding your appeal rights in Georgia can make the difference between approval and costly delays. Counterforce Health helps patients and providers streamline this process by identifying denial reasons and crafting targeted appeals that align with payer-specific requirements.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For assistance with insurance appeals in Georgia, contact the state Department of Insurance Consumer Services at (800) 656-2298.

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