Anthem Blue Cross (HMO, PPO, EPO)
Rydapt (midostaurin)
Drugs for Cancer : Drugs for Cancer
  • 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)

  • 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

  • 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;
  • Quantity Limit: 8 capsules per 1 day(s).
  • PA Applies