Anthem Blue Cross (HMO, PPO, EPO) |
Rydapt (midostaurin) |
Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: 8 capsules per 1 day(s).
- Acute Myeloid Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: FLT3 Mutation Evidence
Quantity Limit: Unspecified
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;In combination with standard cytarabine and daunorubicin induction and cytarabine consolidation;Newly diagnosed acute myeloid leukemia;Post Remission Therapy;Relapsed/Refractory acute myeloid leukemia;Used for re-induction after standard-dose cytarabine induction
Excludes Coverage in Maintenance Setting: Yes
Aggressive Systemic Mastocytosis (ASM): Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- PA Applies
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Aggressive Systemic Mastocytosis (ASM): Documented Diagnosis: Yes
Duration: 1 year(s)
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
For FAX form click HERE Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites: Log in to Surescripts Log in to CoverMyMeds; For details on drug coverage click HERE;
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