By Counterforce Health Team in Vanflyta (quizartinib) —

How to Get Vanflyta (Quizartinib) Covered by Cigna in Ohio: PA Forms, Appeal Process & Cost Assistance

Answer Box: Getting Vanflyta (Quizartinib) Covered by Cigna in Ohio

Vanflyta requires prior authorization from Cigna and must be filled through Accredo specialty pharmacy. To get coverage in Ohio: 1) Have your oncologist submit a PA request with FLT3-ITD test results, prior therapy documentation, and clinical rationale, 2) If denied, file an internal appeal within 180 days with additional evidence, 3) Request external review through the Ohio Department of Insurance if needed. Most approvals occur within 72 hours for standard requests or 24 hours for expedited reviews when medical necessity is clearly documented.

Table of Contents

What Drives Vanflyta Coverage Costs

Understanding your Cigna plan's benefit design helps predict out-of-pocket costs for Vanflyta. The drug appears on different formulary tiers depending on your specific plan—Tier 1 on some Standard plans but Tier 5 on Medicare Advantage plans.

Several factors influence your final cost:

Formulary Tier Placement: Vanflyta's tier determines your copay or coinsurance percentage. Higher tiers mean higher out-of-pocket costs.

Prior Authorization Requirements: All Cigna plans require PA for Vanflyta, which can delay access but doesn't directly affect your copay once approved.

Quantity Limits: Cigna imposes a 56 tablets per 28 days limit across most plans, which aligns with typical dosing.

Specialty Pharmacy Mandate: You must use Accredo specialty pharmacy, which may offer different cost structures than retail pharmacies.

Without insurance, Vanflyta costs approximately $16,100–$17,900 per 28-day supply depending on strength, making coverage approval critical for affordability.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must get approval before filling Cigna member portal or pharmacy Cigna PA Policy
FLT3-ITD Positive Must have confirmed mutation Lab report or genetic testing FDA Label Requirements
Specialty Pharmacy Must use Accredo Accredo enrollment required Cigna Specialty Pharmacy
Quantity Limit 56 tablets per 28 days Prescription limitations Formulary Documents
Appropriate Phase Induction, consolidation, or maintenance Treatment protocol documentation Clinical Guidelines

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who does it: Patient and care team
Documents needed: Insurance card, FLT3-ITD test results, prior therapy records, current treatment plan
Timeline: 1-2 days to collect

2. Submit Prior Authorization Request

Who does it: Oncologist's office
How to submit: Cigna provider portal or fax
Timeline: Same day submission possible
Required elements: Clinical rationale, diagnosis codes, treatment history

3. Enroll with Accredo Specialty Pharmacy

Who does it: Patient or clinic staff
Contact: Accredo at 1-800-803-2523
Timeline: 24-48 hours for enrollment
Documents needed: Prescription, insurance information, patient enrollment form

4. Receive Coverage Decision

Timeline: 72 hours for standard review, 24 hours for expedited
Next steps: If approved, Accredo coordinates delivery; if denied, proceed to appeal

5. File Appeal if Denied

Who does it: Patient or physician
Timeline: Within 180 days of denial
Required: Additional clinical evidence, peer-reviewed studies, treatment guidelines

Benefit Investigation: What to Ask Cigna

Before starting treatment, contact Cigna member services to understand your specific coverage. Here's what to ask and record:

Coverage Questions:

  • "Is Vanflyta covered on my formulary, and what tier?"
  • "What's my copay or coinsurance for Tier [X] specialty drugs?"
  • "Do I have an annual deductible that applies to specialty medications?"
  • "What's my annual out-of-pocket maximum?"

Process Questions:

  • "How do I request prior authorization for Vanflyta?"
  • "What clinical documentation does my doctor need to provide?"
  • "How long does PA review typically take?"
  • "Can I request expedited review if medically urgent?"

Record this information: Reference number, representative name, date/time of call, and specific answers. This documentation helps if you need to reference the conversation later.

Cost Assistance Options

Manufacturer Copay Program

Daiichi Sankyo offers the VANFLYTA Patient Savings Program for commercially insured patients. Eligible patients may pay as little as $0 out-of-pocket per prescription.

Enrollment Process:

  • Contact Daiichi Sankyo Access Central at 1-866-437-4669
  • Work with Accredo specialty pharmacy to complete enrollment
  • Retroactive enrollment available up to 30 days after first treatment

Eligibility: Commercial insurance required (not available for Medicare, Medicaid, or other government programs)

Foundation Assistance

Several patient assistance foundations provide grants for cancer medications. Research foundations that support AML treatments and apply early, as funding is often limited.

Cigna Case Management

For complex or high-cost treatments, request assignment to a Cigna case manager who can help coordinate benefits and identify cost-saving opportunities.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"No FLT3-ITD documentation" Submit genetic testing results Lab report showing FLT3-ITD mutation
"Use outside labeled indications" Clarify appropriate treatment phase Treatment protocol showing induction/consolidation/maintenance
"Step therapy not completed" Request exception with medical rationale Documentation of contraindications to preferred alternatives
"Not medically necessary" Provide clinical evidence Peer-reviewed studies, treatment guidelines, physician letter
"Quantity exceeds limits" Justify dosing requirements Weight-based calculations, FDA dosing guidelines
From our advocates: We've seen cases where initial denials were overturned simply by resubmitting the same clinical information through Cigna's formulary exception process rather than standard PA. Sometimes the review goes to a different clinical team with oncology expertise.

Appeals Process for Ohio Cigna Members

Ohio residents have strong appeal rights with specific timelines and protections.

Internal Appeals (First Level)

Timeline: File within 180 days of denial
Review period: 30 days for standard, 72 hours for expedited
How to file: Written request to Cigna with additional supporting evidence
Required: Denial letter, clinical justification, peer-reviewed studies

Internal Appeals (Second Level)

Timeline: File within 60 days of first-level denial
Review period: 30 days for standard review
Reviewer: Different clinical team than first level

External Review (Ohio Department of Insurance)

Eligibility: After completing internal appeals or if Cigna fails to respond timely
Timeline: File within 180 days of final internal denial
Process: Ohio Department of Insurance assigns Independent Review Organization
Cost: No charge to patient
Decision: Binding on Cigna if overturned

Contact Ohio DOI: 1-800-686-1526 for assistance with external review process

Companies like Counterforce Health specialize in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals that align with each payer's specific requirements.

Specialty Pharmacy Requirements

Cigna requires Vanflyta to be dispensed through Accredo specialty pharmacy, not retail pharmacies. This requirement offers several benefits:

Included Services (No Extra Cost):

  • 24/7 access to specialty-trained pharmacists
  • Medication administration training
  • Refrigerated shipping when needed
  • Refill reminders and coordination

Enrollment Process:

  1. Your oncologist faxes the prescription to Accredo
  2. Accredo contacts you to complete enrollment
  3. They coordinate with Cigna for PA approval
  4. Medication ships to your preferred address

Alternative Specialty Pharmacies: For Vanflyta specifically, you may also use:

  • Biologics by McKesson: 1-800-823-4506
  • Onco360 Oncology Pharmacy: 1-877-662-6355

When to Escalate to Ohio Regulators

If Cigna denies coverage inappropriately or delays the appeal process, Ohio residents can file complaints with state regulators.

File a complaint when:

  • Cigna doesn't respond to appeals within required timeframes
  • Coverage is denied despite meeting all clinical criteria
  • You believe the denial violates Ohio insurance law

Ohio Department of Insurance Consumer Services:

  • Phone: 1-800-686-1526
  • Online complaint portal available
  • Can investigate coverage denials and order external review

Documentation to include:

  • All denial letters and correspondence
  • Clinical records supporting medical necessity
  • Timeline of communications with Cigna
  • Evidence of compliance with PA requirements

For specialized help with complex denials, Counterforce Health helps patients, clinicians, and specialty pharmacies create targeted appeals that address specific denial reasons with evidence-backed rebuttals aligned to each payer's policies.

FAQ

How long does Cigna prior authorization take for Vanflyta in Ohio? Standard PA requests are reviewed within 72 hours. Expedited requests (when delay could jeopardize health) are reviewed within 24 hours.

What if Vanflyta is non-formulary on my Cigna plan? Your physician can request a formulary exception by providing clinical justification for why formulary alternatives are inappropriate.

Can I request expedited review for Vanflyta? Yes, if delaying treatment would seriously jeopardize your health or if you're currently receiving Vanflyta therapy. Your oncologist must certify the urgent medical need.

Does Cigna step therapy apply to FLT3 inhibitors? Step therapy requirements vary by plan. If required, your physician can request an exception by documenting contraindications or previous failures with preferred alternatives.

What happens if I move from Ohio during treatment? Your Cigna coverage travels with you, but appeal rights may change depending on your new state's regulations. Contact Cigna to confirm continued coverage.

How much will Vanflyta cost with Cigna coverage? Costs depend on your specific plan's formulary tier, deductible, and out-of-pocket maximum. Contact Cigna member services with your member ID for exact pricing.

Can I appeal if Cigna approves Vanflyta but limits the quantity? Yes, if the approved quantity is insufficient for appropriate dosing, your physician can request a quantity limit exception with clinical justification.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions depend on your specific insurance plan and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.