By Counterforce Health Team in Vanflyta (quizartinib) —

How to Get Vanflyta (Quizartinib) Covered by Humana in Illinois: Complete PA Guide with Forms and Appeal Process

Answer Box: Getting Vanflyta (Quizartinib) Covered by Humana in Illinois

Vanflyta (quizartinib) is not on most Humana formularies, requiring a formulary exception or prior authorization request with extensive clinical documentation. Your fastest path: Have your oncologist submit FLT3-ITD lab results, AML diagnosis documentation, and medical necessity justification through Humana's provider portal. Start today: Call Humana member services (number on your card) to confirm your plan's specific requirements and initiate the coverage determination process. If denied, Illinois offers strong appeal rights including external review through the state insurance department.

Table of Contents

Plan Types & Coverage Implications

Humana offers several plan types in Illinois, each with different coverage rules for specialty medications like Vanflyta:

Medicare Advantage Plans: These plans have the most restrictive formularies and require prior authorization for most specialty oncology drugs. Humana's Medicare Advantage plans in Illinois typically require step therapy and extensive documentation for non-formulary medications.

Medicare Part D Plans: Standalone prescription drug plans that may cover Vanflyta through the exception process. These plans follow CMS guidelines for coverage determinations and have specific timelines for appeals.

Commercial Plans: Employer-sponsored plans may have more flexibility, but still require prior authorization for high-cost specialty drugs like Vanflyta, which can cost $16,100–$17,900 per 28-day supply.

Note: Your plan type affects your appeal rights and timelines. Medicare beneficiaries have federal protections, while commercial plan members rely on Illinois state laws.

Formulary Status & Alternatives

Current Status: Research indicates Vanflyta is not listed on available 2024-2025 Humana formularies, meaning it requires a formulary exception for coverage.

Preferred Alternatives: Humana typically prefers these FLT3 inhibitors:

  • Midostaurin (Rydapt): Often preferred for newly diagnosed FLT3-positive AML
  • Gilteritinib (Xospata): Preferred for relapsed/refractory FLT3-positive AML

Step Therapy: You may need to try and fail (or have contraindications to) preferred alternatives before Vanflyta approval.

Drug Formulary Status Typical Tier PA Required
Vanflyta (quizartinib) Not listed N/A Exception needed
Midostaurin (Rydapt) Usually covered Tier 4-5 Yes
Gilteritinib (Xospata) Usually covered Tier 4-5 Yes

Prior Authorization Requirements

Essential Documentation

Your oncologist must provide these key documents for Humana prior authorization:

1. FLT3-ITD Mutation Confirmation

  • Laboratory report clearly stating "FLT3-ITD positive"
  • Must be from a certified lab with specific mutation details

2. AML Diagnosis Documentation

  • Clinical notes confirming acute myeloid leukemia diagnosis
  • Appropriate ICD-10 code (typically C92.00)
  • Staging and risk stratification information

3. Treatment History

  • Prior therapies attempted and outcomes
  • Documentation of failure, intolerance, or contraindications to preferred alternatives
  • Rationale for why Vanflyta is medically necessary

4. Safety Monitoring

  • Recent EKG showing QTc ≤450ms (required due to cardiac risks)
  • Baseline cardiac function assessment
  • Plan for ongoing monitoring

5. Prescriber Credentials

Clinician Corner: Medical Necessity Letter Checklist

For Healthcare Providers: Your medical necessity letter should address:Specific FLT3-ITD mutation details and allelic ratio if availableWhy patient is not a candidate for preferred alternatives (Rydapt, Xospata)Treatment phase (induction, consolidation, maintenance) and rationaleCardiac monitoring plan and baseline QTc documentationExpected treatment duration and response monitoring plan

Reference FDA labeling and NCCN guidelines where applicable.

Specialty Pharmacy Network

Vanflyta requires REMS program compliance, limiting dispensing to certified pharmacies:

REMS Requirements:

  • Only REMS-certified pharmacies can dispense
  • Prescriber must be REMS-certified
  • Patient counseling and wallet card required
  • Verification at each dispense

Humana Preferred Specialty Pharmacies: Contact Humana to confirm which specialty pharmacies in their network are REMS-certified for Vanflyta. Common partners include:

  • Humana Pharmacy (verify REMS status)
  • Accredo Specialty Pharmacy
  • CVS Specialty

Quantity Limits: Typical insurance limits are 60 tablets per 30 days for both 17.7mg and 26.5mg strengths.

Cost-Share Considerations

Typical Cost Structure:

  • Tier 5 Specialty: 25-33% coinsurance after deductible
  • Non-formulary: May require full cash price until exception approved

Financial Assistance Options:

  • Daiichi Sankyo Access Central: Manufacturer copay assistance and patient support
  • Foundation support through organizations like Leukemia & Lymphoma Society
  • Illinois pharmaceutical assistance programs for eligible patients
Important: This is educational information only. Actual costs vary by plan. Consult your specific policy documents for exact cost-sharing details.

Submission Process

Step-by-Step: Fastest Path to Approval

1. Confirm Plan Requirements (Patient/Caregiver - Day 1)

  • Call Humana member services (number on insurance card)
  • Request specific PA requirements for Vanflyta
  • Ask about formulary exception process

2. Gather Clinical Documentation (Healthcare Team - Days 1-3)

  • FLT3-ITD lab results
  • Complete AML diagnosis documentation
  • Treatment history and rationale
  • Recent EKG and cardiac assessment

3. Submit Prior Authorization (Prescriber - Day 3-5)

4. Follow Up (All parties - Day 7-10)

  • Track submission status
  • Respond promptly to requests for additional information
  • Prepare for potential peer-to-peer review

Expected Timeline: Standard decisions within 72 hours for Part D; 15 business days for Medicare Advantage pre-service requests.

Common Approval Patterns

Strong Submissions Include:

Component What Works Common Gaps
FLT3-ITD Documentation Specific mutation report with allelic ratio Generic "FLT3 positive" without ITD specification
Prior Therapy Detailed failure/intolerance to Rydapt or Xospata Vague "not appropriate" without specifics
Cardiac Safety Recent EKG with QTc measurement Missing or outdated cardiac assessment
Treatment Plan Specific phase of therapy and monitoring plan Unclear treatment duration or goals

Red Flags That Trigger Denials:

  • Missing FLT3-ITD confirmation
  • No documentation of preferred alternative trials
  • Inadequate cardiac monitoring plan
  • Non-oncology prescriber without consultation

Appeals Process in Illinois

If your Vanflyta request is denied, Illinois provides robust appeal rights:

Internal Appeals

Timeline: 60 days from denial to file appeal Decision Deadline:

  • 15 business days for pre-service requests
  • 24 hours for expedited appeals

How to File:

Illinois External Review

When Available: After exhausting internal appeals Timeline: Must file within 4 months (120 days) of final denial Process: Independent physician review through Illinois Department of Insurance Cost: Free to patients; paid by Humana Decision: Binding on Humana

Contact Illinois DOI:

Appeals Documentation Checklist

  • Original denial letter
  • All clinical documentation submitted with PA
  • Updated medical necessity letter addressing denial reasons
  • Evidence of step therapy completion or contraindications
  • Recent treatment response documentation
  • Appointment of Representative form (if applicable)
From Our Advocates: We've seen successful appeals when families work closely with their oncology team to address each specific denial reason. One common pattern: initial denials for "insufficient documentation of FLT3-ITD mutation" were overturned when families provided the complete lab report with specific mutation details and allelic ratio. The key is thorough documentation that directly addresses Humana's criteria.

FAQ

How long does Humana prior authorization take for Vanflyta in Illinois? Standard requests: 72 hours for Part D, 15 business days for Medicare Advantage. Expedited requests: 24 hours if delay would jeopardize health.

What if Vanflyta is completely non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Your oncologist must explain why preferred alternatives are inappropriate.

Can I request expedited review? Yes, if a delay would seriously jeopardize your health or ability to regain maximum function. Your oncologist must provide clinical justification for urgency.

Does step therapy apply if I tried alternatives outside Illinois? Yes, document any prior trials of midostaurin or gilteritinib regardless of where treatment occurred. Include records showing failure or intolerance.

What happens if Humana denies my appeal? You can request external review through the Illinois Department of Insurance. An independent physician will review your case, and their decision is binding.

How much does Vanflyta cost without insurance? Approximately $16,100–$17,900 per 28-day supply. Manufacturer assistance programs may help reduce costs.

Resources

Key Forms and Contacts

Clinical References

Patient Advocacy

At Counterforce Health, we help patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that address specific payer requirements, helping turn denials into approvals for medications like Vanflyta.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, contact the Illinois Department of Insurance at 877-527-9431 or visit insurance.illinois.gov.

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