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

Get Tavalisse (fostamatinib) Covered by UnitedHealthcare in Virginia: Complete Prior Authorization Guide with Forms and Appeal Process

Answer Box: Getting Tavalisse Covered by UnitedHealthcare in Virginia

UnitedHealthcare requires prior authorization for Tavalisse (fostamatinib) through OptumRx, with mandatory step therapy documentation showing failure of corticosteroids and thrombopoietin receptor agonists. Submit requests via the UnitedHealthcare Provider Portal with complete clinical documentation. If denied, Virginia offers a robust external review process through the State Corporation Commission Bureau of Insurance using Form 216-A within 120 days. Start today: Have your hematologist gather prior therapy documentation and platelet count records before submitting the PA request.

Table of Contents

  1. Verify Your Plan and Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Process
  4. Fax and Mail Options
  5. Specialty Pharmacy Enrollment
  6. Support Lines and Contacts
  7. Virginia External Review Process
  8. Appeals Timeline and Updates

Verify Your Plan and Coverage

Before starting your Tavalisse prior authorization, confirm your UnitedHealthcare plan details and coverage requirements.

Coverage at a Glance

Requirement What it means Where to find it Source
Prior Authorization Required for all Tavalisse prescriptions UnitedHealthcare PA Policy OptumRx
Step Therapy Must document failure of corticosteroids AND TPO-RA Same policy document OptumRx
Specialist Requirement Board-certified hematologist must prescribe UnitedHealthcare Provider Portal UHC Provider
Initial Authorization 12 months if approved PA notification form OptumRx
Reauthorization Documentation of clinical response required Same policy document OptumRx
Note: Virginia patients with Cardinal Care Medicaid must use the UnitedHealthcare Provider Portal exclusively for PA submissions.

Prior Authorization Forms and Requirements

Required Clinical Documentation

Your hematologist must submit the following through the UnitedHealthcare Provider Portal:

Diagnosis Documentation:

  • Chronic ITP diagnosis confirmed by hematologist
  • ICD-10 code D69.3 for chronic immune thrombocytopenia
  • Complete blood count with platelet count (typically <30,000/μL)
  • Peripheral blood smear results

Step Therapy Documentation:

  1. Corticosteroids - Document trial and failure/intolerance of prednisone, methylprednisolone, or dexamethasone
  2. Thrombopoietin Receptor Agonist - Must show inadequate response to either eltrombopag (Promacta) or romiplostim (Nplate)

Clinical Justification:

  • Medical necessity letter from prescribing hematologist
  • Treatment goals and monitoring plan
  • Contraindications to alternative therapies (if applicable)

Processing Timelines

UnitedHealthcare processes Tavalisse prior authorizations according to these timelines:

  • Standard reviews: Up to 15 business days
  • Expedited reviews: 24-72 hours for urgent medical conditions
  • Reauthorizations: Submit 30 days before current authorization expires

Submission Portals and Upload Process

UnitedHealthcare Provider Portal

Access the portal at UHCprovider.com using your One Healthcare ID. Navigate to the "Prior Authorization and Notification" tab on your dashboard.

Upload Requirements:

  • Submit requests for the entire plan of care, including full duration
  • Include all clinical documentation in a single submission
  • Verify member eligibility before submitting to ensure accurate processing

Phone Submission Option

For assistance with prior authorization requests, call 866-889-8054. This line can help with submission questions and status updates.

Tip: Check member eligibility first to get the most accurate response regarding PA requirements for your specific patient's plan.

Fax and Mail Options

While UnitedHealthcare encourages online submissions through the provider portal, alternative submission methods may be available. Contact 866-889-8054 to confirm current fax numbers and mailing addresses for your specific plan type.

Cover Sheet Best Practices:

  • Include patient's full name and member ID
  • Mark "URGENT" for expedited requests
  • List all attached documents
  • Include provider contact information for follow-up

Specialty Pharmacy Enrollment

Once your Tavalisse prior authorization is approved, the prescription routes through OptumRx's specialty pharmacy network.

Approved Specialty Pharmacies

UnitedHealthcare works with these specialty pharmacies for Tavalisse:

  • Biologics by McKesson
  • Optime Care Specialty Pharmacy
  • Other OptumRx network specialty pharmacies

Enrollment Process

  1. Complete the TAVALISSE Enrollment and Patient Assistance Program Form
  2. Fax completed form to 833-397-4435
  3. Select your preferred specialty pharmacy from the OptumRx network
  4. Coordinate with the specialty pharmacy for delivery scheduling

Cost Considerations

  • Without insurance: Approximately $14,000-$16,000 per 60-tablet bottle
  • With UnitedHealthcare: Specialty tier copays typically $100-$500+ per month
  • Patient assistance: Contact RIGEL ONECARE at 833-744-3562 for copay support

Support Lines and Contacts

Member Services

  • UnitedHealthcare Member Services: Use the number on your insurance card
  • OptumRx: For pharmacy benefit questions and PA status

Provider Support

  • Prior Authorization Help: 866-889-8054
  • Clinical Review: Request peer-to-peer review if initial PA is denied

Patient Assistance

Virginia External Review Process

If UnitedHealthcare denies your Tavalisse prior authorization after internal appeals, Virginia's external review process provides an independent assessment.

Step-by-Step External Review Process

1. Complete Internal Appeals First You must exhaust UnitedHealthcare's internal appeal process before requesting external review. You have 180 days from the denial notice to file an internal appeal.

2. Submit Form 216-A After receiving a final adverse determination from UnitedHealthcare, submit your external review request using Form 216-A (External Review Request Form) within 120 days.

3. Submit to Virginia Bureau of Insurance Email your completed Form 216-A and supporting documentation to the Virginia State Corporation Commission Bureau of Insurance at [email protected]

Review Timelines

  • Standard external review: 45 days for a decision
  • Expedited external review: 72 hours (requires Form 216-C physician certification)

No Cost to Consumers

Virginia's external review process is completely free - there are no fees for consumers.

Important: If your case involves urgent medical necessity, your healthcare provider can complete Form 216-C to request expedited review, which must be decided within 72 hours.

Appeals Timeline and Updates

Internal Appeal Process

Step Timeline Action Required Contact
Initial PA Denial Day 0 File internal appeal within 180 days UHC Member Services
Standard Review 30-60 days Await decision; submit additional documentation if requested 866-889-8054
Urgent Review 72 hours Available for time-sensitive medical conditions Same

External Review Process

Step Timeline Action Required Contact
Final Internal Denial Day 0 File Form 216-A within 120 days VA Bureau of Insurance
Standard External Review 45 days Submit additional documentation within 5 business days if requested [email protected]
Expedited External Review 72 hours Physician must complete Form 216-C certification Same

When to Update Your Resources

  • Monthly: Check UnitedHealthcare provider portal for policy updates
  • Quarterly: Review Virginia Bureau of Insurance forms for any changes
  • Before each submission: Verify current PA requirements and forms
  • After plan changes: Confirm step therapy requirements haven't changed

Clinician Corner: Medical Necessity Letter

When drafting your medical necessity letter for Tavalisse, include these key elements:

Clinical Problem:

  • Document chronic ITP duration (>12 months)
  • Current platelet count and bleeding risk
  • Impact on patient's quality of life and daily activities

Prior Treatment Documentation:

  • Specific corticosteroids tried, doses, duration, and reasons for discontinuation
  • TPO-RA therapy details (eltrombopag or romiplostim) and clinical response
  • Any other relevant treatments attempted

Clinical Rationale:

  • Reference FDA approval for chronic ITP with insufficient response to previous therapy
  • Cite relevant hematology guidelines supporting Tavalisse use
  • Explain why alternative treatments are inappropriate or contraindicated

Monitoring Plan:

  • Liver function test monitoring schedule
  • Blood pressure monitoring
  • Complete blood count follow-up
  • Treatment goals and success metrics

FAQ

How long does UnitedHealthcare PA take in Virginia? Standard prior authorization reviews take up to 15 business days. Expedited reviews for urgent medical conditions are processed within 24-72 hours.

What if Tavalisse is non-formulary on my plan? You can request a formulary exception with supporting clinical documentation demonstrating medical necessity and failure of formulary alternatives.

Can I request an expedited appeal in Virginia? Yes, both UnitedHealthcare internal appeals and Virginia external reviews offer expedited options for urgent medical conditions requiring physician certification.

Does step therapy apply if I failed treatments outside Virginia? Yes, step therapy documentation from any location is acceptable as long as it's properly documented by a qualified healthcare provider.

What happens if the Virginia external review overturns the denial? UnitedHealthcare must provide coverage within 1-3 days. For expedited reviews, authorization must occur within 24 hours.

Can I get help with the appeals process in Virginia? Yes, contact the Virginia State Corporation Commission Consumer Services at 1-877-310-6560 for guidance on the external review process.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for patients seeking coverage of specialty medications like Tavalisse. The platform helps identify denial reasons and drafts point-by-point rebuttals aligned to each plan's specific requirements, pulling the right citations and clinical documentation to support medical necessity arguments.

For patients navigating complex prior authorization requirements, having the right documentation and understanding payer-specific workflows can make the difference between approval and denial. Counterforce Health's approach to analyzing denial letters and plan policies helps ensure that appeals address the specific criteria UnitedHealthcare uses to evaluate Tavalisse requests.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for the most current requirements and procedures. Coverage decisions depend on individual medical circumstances and plan benefits.

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