By Counterforce Health Team in Tavalisse (fostamatinib disodium hexahydrate) —

Do You Qualify for Tavalisse Coverage by Cigna in Georgia? Decision Tree & Next Steps

Answer Box: Getting Tavalisse Covered by Cigna in Georgia

Most likely to get approved: Adults with chronic ITP (12+ months), platelet count <30,000/mcL or <50,000/mcL with bleeding risk, who've failed at least one prior therapy (steroids, IVIG), and have a hematologist prescriber. Fastest path: Have your hematologist submit prior authorization through Cigna's provider portal with complete treatment history and current platelet counts. First step today: Call Cigna member services at the number on your insurance card to confirm your plan requires prior authorization and get the submission fax number. If denied, Georgia law gives you 60 days to file an external review with the state Department of Insurance.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Your Action Plan
  4. If "Possibly Eligible" - Tests and Timeline
  5. If "Not Yet" - Alternative Pathways
  6. If Denied - Georgia Appeal Process
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Fixes
  9. FAQ
  10. Sources & Further Reading

How to Use This Decision Tree

This guide helps you determine if you qualify for Tavalisse (fostamatinib disodium hexahydrate) coverage through Cigna in Georgia, and what to do next based on your situation.

Before you start, gather these documents:

  • Insurance card with member ID
  • Recent platelet count results (within 30 days)
  • Complete list of ITP treatments you've tried
  • Contact information for your hematologist
  • Any previous denial letters from Cigna

Time commitment: Initial assessment takes 10-15 minutes. Full prior authorization process typically takes 1-4 weeks.

Eligibility Triage: Do You Qualify?

Work through these questions to determine your approval likelihood:

1. Age and Diagnosis Requirements

✅ Are you 18 or older? Cigna requires adult patients

✅ Do you have chronic ITP lasting 12+ months? Chronic immune thrombocytopenia must be documented in your medical records.

2. Platelet Count Criteria

Your current platelet count must meet one of these thresholds:

  • Less than 30,000/mcL (30 × 10⁹/L), OR
  • Less than 50,000/mcL (50 × 10⁹/L) with documented bleeding risk

3. Prior Treatment Failure

✅ Have you tried and failed at least one of these treatments?

  • Systemic corticosteroids (prednisone, methylprednisolone, dexamethasone)
  • Intravenous immunoglobulin (IVIG)
  • Anti-D immunoglobulin
  • Eltrombopag (Promacta)

4. Prescriber Requirements

✅ Is your prescriber a hematologist or working in consultation with one? Cigna requires hematology expertise for Tavalisse prescriptions.

Your Result:

  • All 4 criteria met = Likely Eligible → Go to Section 3
  • 3 criteria met = Possibly Eligible → Go to Section 4
  • 2 or fewer criteria met = Not Yet → Go to Section 5

If "Likely Eligible" - Your Action Plan

Congratulations! You meet Cigna's standard approval criteria. Here's your step-by-step path:

Document Checklist for Prior Authorization

Your hematologist will need to submit:

Required Clinical Information:

  • Current platelet count (within 30 days)
  • Chronic ITP diagnosis with duration confirmation
  • Complete prior treatment history with specific medications, dates, and reasons for failure
  • Current bleeding risk assessment
  • Prescriber attestation of medical necessity

Supporting Documentation:

  • Recent CBC with platelet count
  • Treatment failure documentation (previous prescriptions, clinic notes)
  • Hematology consultation notes (if prescribed by non-hematologist)

Submission Process

  1. Contact Cigna (member services number on your card) to confirm prior authorization requirements
  2. Have your hematologist submit via Cigna provider portal or designated fax line
  3. Timeline: Standard review completed within 72 hours of complete submission
  4. Follow up if no response within 5 business days
Tip: Ask your hematologist's office to mark the request as "urgent" if your platelet count is critically low or you're experiencing bleeding symptoms.

If "Possibly Eligible" - Tests and Timeline

You're close to meeting approval criteria but need additional documentation or testing.

Common Missing Elements and Solutions:

If you haven't tried required prior therapies:

  • Discuss with your hematologist trying corticosteroids or IVIG first
  • Document any contraindications that prevent standard treatments
  • Timeline: 4-12 weeks for treatment trial

If your platelet count is too high (>50,000/mcL):

  • Request documentation of bleeding risk factors
  • Monitor for count fluctuations over 2-4 weeks
  • Consider bleeding questionnaire assessment

If you need hematology consultation:

  • Request referral from primary care physician
  • Average wait time for hematology: 2-6 weeks in Georgia
  • Some hematologists offer expedited consultations for active bleeding

Reapplication Strategy

Plan to resubmit your prior authorization once missing elements are addressed. Keep detailed records of all treatments tried and their outcomes.

If "Not Yet" - Alternative Pathways

Don't give up! Several options remain available:

Formulary Exception Request

Even if you don't meet standard criteria, you can request an exception based on:

  • Medical contraindications to preferred treatments
  • Previous adverse reactions to formulary alternatives
  • Unique clinical circumstances

Submit exception requests through Cigna's formulary exception process with detailed clinical justification.

Alternative Treatments to Discuss

Work with your hematologist to consider:

  • TPO receptor agonists: Eltrombopag (Promacta), romiplostim (Nplate)
  • Immunosuppressives: Rituximab, azathioprine
  • Surgical options: Splenectomy evaluation

Patient Assistance Programs

While working toward coverage approval:

  • Rigel Pharmaceuticals patient support: Contact manufacturer directly
  • Foundation grants: National Organization for Rare Disorders (NORD)
  • State programs: Georgia pharmacy assistance programs (verify with Georgia DOI)

If Denied - Georgia Appeal Process

Georgia provides strong consumer protections for insurance appeals. Here's your roadmap:

Internal Appeal (First Level)

Timeline: Must file within 180 days of denial

How to file:

  1. Call Cigna member services to initiate appeal
  2. Submit written appeal with additional clinical evidence
  3. Request peer-to-peer review with Cigna medical director

Review time: 24 hours for expedited, 72 hours for standard

External Review (Georgia Department of Insurance)

If internal appeal fails, Georgia law provides independent review:

Timeline: 60 days from internal appeal denial to file with Georgia DOI

Contact Information:

Review Process:

  • Independent medical experts review your case
  • 30 business days for standard review
  • 72 hours for urgent medical situations
  • Decision is binding on Cigna under Georgia law
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform can help identify the specific denial basis and draft point-by-point rebuttals aligned to Cigna's own coverage rules.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Cigna approval needed before filling Cigna PA Policy
Age Limit 18 years or older FDA labeling requirement
Diagnosis Chronic ITP (12+ months) Medical records documentation
Platelet Count <30,000 OR <50,000 with bleeding risk Recent CBC results
Prior Therapy Failed ≥1 standard treatment Treatment history records
Prescriber Hematologist or consultation Specialist involvement required
Review Timeline 72 hours standard, 24 hours expedited Cigna policy timelines
Appeal Deadline 180 days internal, 60 days external Georgia insurance law

Common Denial Reasons & Fixes

Denial Reason How to Overturn
"No prior therapy documented" Submit complete treatment history with dates, dosages, and outcomes
"Platelet count too high" Provide bleeding risk documentation or wait for lower count
"Not prescribed by hematologist" Obtain hematology consultation notes
"Insufficient clinical information" Submit recent labs, CBC, and detailed clinical notes
"Step therapy not completed" Document contraindications or failures with preferred agents
"Experimental/investigational" Cite FDA approval and established indication

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Tavalisse in Georgia? A: Standard reviews are completed within 72 hours, expedited reviews within 24 hours of receiving complete documentation.

Q: What if Tavalisse is non-formulary on my Cigna plan? A: You can request a formulary exception through Cigna's exception process with clinical justification from your hematologist.

Q: Can I request an expedited appeal if I'm bleeding? A: Yes, both Cigna internal appeals and Georgia external reviews offer expedited pathways for urgent medical situations.

Q: Does step therapy apply if I failed treatments outside Georgia? A: Treatment history from any location counts toward meeting prior therapy requirements, as long as it's properly documented.

Q: What's the cost of Tavalisse without insurance? A: Wholesale acquisition cost is approximately $14,000-$16,000 per 60-tablet bottle, but patient assistance programs may be available.

Q: How does Georgia's external review work? A: Independent medical experts review your case within 30 days, and their decision is binding on Cigna under Georgia law.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes to identify the denial basis and draft point-by-point rebuttals aligned to the plan's own rules.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan type and may change. Always verify current requirements with Cigna directly and consult your healthcare provider about treatment decisions. For assistance with appeals, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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