Health Net
Rydapt (midostaurin)
Drugs for Cancer : Drugs for Cancer
  • Acute Myeloid Leukemia:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Drug Policy Based On: Payer Specific
    Supporting Documentation Requirements: 2 of Chart Notes;FLT3 mutation as detected by an FDA-approved test
    Quantity Limit: N/A
    Criteria for Reauthorization: Member is responding positively to therapy
    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
    Excludes Coverage in Maintenance Setting: Yes

    Aggressive Systemic Mastocytosis (ASM):
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Allergist;Immunologist;Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

  • Prior Authorization: Acute Myeloid Leukemia:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

    Aggressive Systemic Mastocytosis (ASM):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

  • Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.