By Counterforce Health Team in Vanflyta (quizartinib) —

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

Answer Box: To get Vanflyta (quizartinib) covered by Aetna CVS Health in Ohio, you'll need prior authorization with FLT3-ITD testing documentation, baseline EKG showing QTc ≤450ms, and hematologist/oncologist prescription. Submit through CVS Caremark's electronic portal or specialty pharmacy channels. If denied, use Aetna's 180-day internal appeal process, then Ohio's external review through the Department of Insurance. Start by calling the member services number on your insurance card to verify formulary status and obtain the current PA form.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Required Prior Authorization Forms
  3. Submission Portals and Electronic Channels
  4. Fax and Mail Submission Details
  5. CVS Specialty Pharmacy Requirements
  6. Support Lines and Contact Directory
  7. Appeals Process: Internal and External Review
  8. Ohio Department of Insurance External Review
  9. Common Denial Reasons and Solutions
  10. Cost Assistance and Patient Support
  11. FAQ: Vanflyta Coverage in Ohio

Start Here: Verify Your Plan and Find Forms

Before requesting Vanflyta (quizartinib) coverage, confirm your specific Aetna CVS Health plan details:

Step 1: Check Your Coverage Type

  • Call the member services number on your insurance card
  • Ask specifically about "Vanflyta prior authorization requirements"
  • Verify if your plan is commercial, Medicare Advantage, or Medicaid managed care
  • Confirm whether CVS Specialty Pharmacy is required

Step 2: Download Current Forms Aetna updates PA forms regularly. Access the most current version through:

Note: Vanflyta requires prior authorization across essentially all Aetna CVS Health plan types in 2024, including commercial, Medicare Advantage, and most Medicaid managed care products.

Coverage at a Glance

Requirement What It Means Where to Find It Source
PA Required Yes, all plan types Member services or formulary Aetna Precert List
Formulary Tier Specialty/Tier 4-5 Plan documents Plan-specific formulary
Step Therapy May require trial of other FLT3 inhibitors PA criteria document Verify with plan
Quantity Limits 28-day supply typical Pharmacy benefits CVS Caremark
Site of Care CVS Specialty required Member handbook Plan documents
Diagnosis Codes C92.00 (AML, unspecified) ICD-10 manual Clinical documentation

Required Prior Authorization Forms

Commercial Plans

  • Form: Vanflyta Prior Authorization Request
  • Key Requirements:
    • FLT3-ITD mutation documentation
    • Baseline EKG with QTc measurement
    • Hematologist/oncologist NPI
    • Treatment phase (induction, consolidation, maintenance)

Medicare Advantage

  • Process: Coverage determination request
  • Timeline: 72 hours for expedited, 14 days standard
  • Special Requirements: CMS guidelines for off-label use if applicable

Medicaid (Aetna Better Health)

  • State-Specific Forms: Ohio Medicaid PA requirements
  • Additional Documentation: Prior therapy failures, contraindications to alternatives

Clinician Corner: Medical Necessity Letter Checklist

When submitting a PA or appeal for Vanflyta, include these elements in your medical necessity letter:

✓ Diagnosis: Newly diagnosed FLT3-ITD–positive AML with pathology confirmation
✓ Mutation Testing: FLT3-ITD results from validated molecular assay
✓ Treatment Phase: Specify induction, consolidation, or maintenance
✓ Prior Therapies: Document any previous AML treatments and outcomes
✓ Safety Monitoring: Baseline EKG showing QTc ≤450ms, electrolyte levels
✓ Guideline Support: Reference NCCN guidelines for FLT3-mutated AML
✓ Contraindications: Any reasons other FLT3 inhibitors aren't appropriate

Submission Portals and Electronic Channels

For Providers

CVS Caremark Provider Portal

  • URL: Access through Caremark provider resources
  • Account Required: Yes, NCPDP and NPI verification needed
  • Electronic PA: Preferred method, faster processing

CoverMyMeds Integration

  • Many EHR systems integrate with CoverMyMeds for Aetna submissions
  • Electronic workflow reduces processing time to 24-48 hours

For Members

CVS Specialty Portal

  • URL: CVS Specialty sign-in
  • Use for: Tracking PA status, managing refills, messaging care team
  • Registration: Requires prescription details and member ID

Fax and Mail Submission Details

Important: Always verify current fax numbers with member services, as these change frequently.

Standard Submissions

  • Fax: Use the fax number provided in your denial letter or PA form
  • Mail: Include all supporting documentation and use certified mail for appeals
  • Cover Sheet Tips: Include member ID, prescriber NPI, and "URGENT" if expedited

Required Attachments

  1. Completed PA form
  2. FLT3-ITD lab results
  3. Baseline EKG report
  4. Pathology/bone marrow biopsy report
  5. Treatment history summary
  6. Medical necessity letter

CVS Specialty Pharmacy Requirements

Vanflyta must typically be dispensed through CVS Specialty Pharmacy for most Aetna plans:

Enrollment Steps:

  1. PA approval obtained
  2. Prescription sent to CVS Specialty
  3. Patient enrollment call (financial counseling, delivery setup)
  4. First shipment coordination

Transfer Instructions:

  • Current pharmacy can transfer to CVS Specialty
  • Call CVS Specialty at the number on your insurance card
  • Have prescription number and prescriber information ready

Support Lines and Contact Directory

Member Services

  • Primary: Number on your insurance card (plan-specific)
  • Hours: Typically 8 AM - 8 PM local time
  • What to Ask: PA status, formulary tier, appeal deadlines

Provider Relations

  • Access: Through member services or provider portal
  • Best for: PA questions, peer-to-peer reviews, billing issues

Case Management

  • Request: Through member services
  • Services: Complex case coordination, prior authorization assistance
  • Timeline: 1-2 business day callback typical

Appeals Process: Internal and External Review

Aetna Internal Appeals

Timeline: 180 days from denial date to file
Levels: Single internal review for most commercial plans
Expedited: Available when delay could jeopardize health

Required Documentation:

  • Appeal form or written request
  • Copy of denial letter
  • Updated medical necessity letter
  • Additional clinical support (recent labs, imaging, notes)

Step-by-Step Appeal Process

  1. Gather Documents (1-2 days)
    • Denial letter with specific reasons
    • Complete medical records
    • Updated physician letter
  2. Submit Appeal (Same day)
    • Use portal, fax, or certified mail
    • Request expedited review if clinically urgent
    • Keep copies of all submissions
  3. Track Status (Ongoing)
    • Standard: 30 days for decision
    • Expedited: 72 hours
    • Call member services for updates
  4. Prepare for Peer-to-Peer (If offered)
    • Oncologist should be available for medical review
    • Have clinical rationale and guidelines ready

Ohio Department of Insurance External Review

After exhausting Aetna's internal appeals, Ohio residents can request external review:

Eligibility: Medical necessity denials, formulary exceptions
Timeline: 180 days from final internal denial
Process: Independent medical experts review case
Binding: Decision is final and binding on Aetna

How to File External Review

  1. Complete Internal Appeals: Must finish Aetna's process first
  2. Get Forms: Ohio Department of Insurance external review
  3. Submit Documentation: Include all medical records and Aetna's final denial
  4. Track Timeline: 30 days standard, 72 hours expedited

Contact Information:

  • Ohio Department of Insurance Consumer Hotline: 1-800-686-1526
  • Online assistance: ODI complaint center

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
No FLT3-ITD documentation Submit lab report Molecular pathology results with mutation details
Use outside labeled phases Clarify treatment phase Physician letter explaining induction/consolidation/maintenance
EKG/QT monitoring not addressed Provide cardiac safety data Baseline EKG showing QTc ≤450ms, electrolyte panel
Step therapy not met Document contraindications Medical necessity letter explaining why alternatives aren't suitable
Non-formulary status Request formulary exception Comprehensive clinical rationale with guideline support

Cost Assistance and Patient Support

Manufacturer Support

  • Daiichi Sankyo Patient Assistance: Contact through prescriber or manufacturer website
  • Copay Cards: May reduce out-of-pocket costs for commercially insured patients
  • Free Drug Programs: Available for eligible uninsured/underinsured patients

Foundation Grants

  • Leukemia & Lymphoma Society
  • Patient Access Network Foundation
  • CancerCare Co-Payment Assistance Foundation

State Programs

  • Ohio pharmaceutical assistance programs for Medicare beneficiaries
  • Medicaid coverage for eligible patients

From Our Advocates

We've seen cases where patients initially faced step-therapy requirements for Vanflyta, but successful appeals emphasized the aggressive nature of FLT3-ITD–positive AML and the time-sensitive need for optimal therapy. Including recent bone marrow biopsy results showing high blast counts and citing NCCN guidelines strengthened these appeals significantly.

FAQ: Vanflyta Coverage in Ohio

How long does Aetna CVS Health PA take in Ohio?
Standard PA decisions typically take 5-7 business days. Expedited reviews for urgent cases are completed within 72 hours. Electronic submissions through provider portals are faster than fax.

What if Vanflyta is non-formulary on my plan?
Request a formulary exception with comprehensive medical documentation. Include FLT3-ITD test results, treatment history, and physician letter explaining medical necessity.

Can I request an expedited appeal?
Yes, if delays could seriously jeopardize your health. Document rapid disease progression, high blast counts, or transplant timing considerations.

Does step therapy apply if I've failed treatments outside Ohio?
Prior treatment history from any location counts. Provide complete documentation of previous therapies, responses, and reasons for discontinuation.

How much does Vanflyta cost without insurance?
Cash prices range from approximately $16,100-$17,900 per 28-day supply. Manufacturer assistance programs may significantly reduce costs for eligible patients.

What happens if my external review is denied?
External review decisions are binding, but you retain rights to file regulatory complaints or seek legal remedies. Consider consulting with a healthcare attorney for complex cases.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right citations and clinical evidence to support coverage requests for medications like Vanflyta.

When facing complex prior authorization requirements or appeals for specialty medications, having the right documentation and strategy can make the difference between approval and denial. Counterforce Health streamlines this process by identifying specific denial reasons and crafting responses that address payer criteria directly.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and state. Always consult with your healthcare provider about treatment decisions and verify current requirements with your insurance plan. For specific questions about Ohio insurance regulations, contact the Ohio Department of Insurance at 1-800-686-1526.

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