UnitedHealthcare
Rydapt (midostaurin)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Acute Myeloid Leukemia:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: < 19
    Duration: 12 Month(s)
    Reauthorization Required: Yes

    Aggressive Systemic Mastocytosis (ASM):
    Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Quantity Limit: limit maximum 8 EA PER 1 day(s)
  • Orally administered anticancer medication.
  • Acute Myeloid Leukemia:
    Age Requirement: < 19
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Quantity Limit: N/A
    Criteria for Reauthorization: No evidence of disease progression or unacceptable toxicity
    Use of Biomarkers in Policy: FLT3 mutation
    Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;Induction therapy OR Consolidation therapy ;Medically accepted uses supported by NCCN Category 1, 2A or 2B level of evidence
    Excludes Coverage in Maintenance Setting: No

    Aggressive Systemic Mastocytosis (ASM):
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)