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

Getting Tavalisse (Fostamatinib) Approved by Humana in Georgia: Complete Guide to Prior Authorization and Appeals

Answer Box: Your Path to Tavalisse Coverage in Georgia

Tavalisse (fostamatinib) requires prior authorization from Humana and typically isn't on standard formularies. To get coverage in Georgia: (1) Document chronic ITP diagnosis with platelet count <30,000/μL, (2) show failure of corticosteroids and at least one TPO receptor agonist (eltrombopag or romiplostim), and (3) have your hematologist submit a prior authorization request with complete clinical documentation. If denied, you have 65 days to appeal and can request Georgia DOI external review for non-Medicare plans.

Table of Contents

Understanding Tavalisse Coverage Requirements

Tavalisse (fostamatinib disodium hexahydrate) is a specialty medication for chronic immune thrombocytopenia (ITP) that costs approximately $14,000-$16,000 per 60-tablet bottle. Humana Medicare Advantage plans require prior authorization and the drug is typically non-formulary, meaning it's not on their standard covered drug list.

Coverage at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Pre-approval required before dispensing Complete PA form with clinical justification Humana PA Portal
Step Therapy Must try other treatments first Records of corticosteroids + TPO agonist failure Humana Formulary Guidelines
Specialist Prescriber Hematologist or ITP specialist required Prescriber credentials and consultation notes FDA Label Requirements
Platelet Count <30,000/μL (or <50,000 with bleeding risk) Recent lab results within 30 days Clinical Guidelines
Diagnosis Confirmation Chronic ITP, primary type ICD-10 code D69.3 and clinical documentation Medical Records
Note: For Medicare Advantage plans, appeals follow federal timelines. For commercial Humana plans in Georgia, state external review through the Georgia DOI is available.

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Lab Values

Who: Your hematologist
Timeline: Before starting the PA process
Documents needed: Recent CBC with platelet count, bone marrow biopsy results (if performed), diagnosis confirmation

Your platelet count must be documented as less than 30,000/μL (30 x 10⁹/L) or less than 50,000/μL with increased bleeding risk. The diagnosis of chronic ITP should be established for at least 12 months.

2. Document Prior Treatment Failures

Who: Your medical team
Timeline: Gather records from past 12-24 months
Documents needed: Medication lists, treatment dates, response documentation

You must have tried and failed (or have contraindications to):

  • Corticosteroids (prednisone, dexamethasone)
  • At least one TPO receptor agonist (eltrombopag/Promacta or romiplostim/Nplate)
  • Additional therapies may include IVIG, rituximab, or splenectomy

3. Complete the Prior Authorization Request

Who: Your prescriber or their staff
Timeline: Allow 5-7 business days for processing
Submit via: Humana Provider Portal or fax to 1-877-486-2621

The PA request must include:

  • Completed Humana specialty drug PA form
  • Clinical notes supporting medical necessity
  • Lab results showing qualifying platelet counts
  • Documentation of prior therapy failures
  • Treatment goals and monitoring plan

4. Track Your Request Status

Who: Patient or clinic staff
Timeline: Check after 3-5 business days
Method: Humana member portal or provider portal

Humana typically responds to specialty drug PAs within 7 days for Part D requests and up to 30 days for medical benefit requests.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents to Submit
"Step therapy not completed" Provide detailed records of prior treatments Medication history with dates, doses, and reasons for discontinuation
"Not prescribed by specialist" Ensure hematologist is prescribing Referral letter and specialist consultation notes
"Platelet count doesn't meet criteria" Submit recent labs showing qualifying counts CBC results within 30 days showing <30,000/μL
"Medical necessity not established" Strengthen clinical justification Bleeding history, quality of life impact, treatment goals
"Non-formulary drug" Request formulary exception Comparison showing why formulary alternatives won't work
From our advocates: We've seen cases where the initial denial cited "insufficient documentation of prior therapy failures," but when the clinic resubmitted with a detailed timeline showing specific dates, doses, and clinical responses to corticosteroids and eltrombopag, the approval came through within a week. The key is being thorough with your treatment history documentation.

Appeals Process for Georgia Residents

If your initial prior authorization is denied, you have multiple levels of appeal available:

Internal Appeals (Humana)

Timeline: 65 days from denial notice
Decision deadline: 30 days (pre-service), 7 days (Part D drugs)
How to file: Written appeal via Humana member portal or mail

Include new clinical evidence, peer-reviewed studies supporting Tavalisse use, and any additional documentation from your hematologist.

Expedited Appeals

When to use: If waiting endangers your health
Decision deadline: 72 hours
Requirements: Provider must attest that standard timeline poses health risk

External Review Options

For Medicare Advantage: Automatic referral to Independent Review Entity (IRE) if internal appeal fails
For Commercial Plans: Georgia DOI external review within 60 days of final internal denial

Georgia DOI Contact:
Phone: 1-800-656-2298
Online: Insurance complaint form

The external review process in Georgia is free for consumers and typically takes 30 business days for standard reviews.

Medical Necessity Documentation Checklist

When Counterforce Health helps clinicians prepare prior authorization requests, we ensure these key elements are included:

Required Clinical Information

  • Diagnosis: Chronic ITP (ICD-10: D69.3) with duration >12 months
  • Platelet count: Recent lab showing <30,000/μL or <50,000/μL with bleeding risk
  • Prior therapies: Detailed list with dates, doses, duration, and outcomes
  • Bleeding history: Documentation of bleeding episodes or risk factors
  • Contraindications: Any reasons why standard therapies cannot be used
  • Treatment goals: Target platelet count and clinical objectives
  • Monitoring plan: How response will be assessed and safety monitored

Supporting Evidence

  • FDA labeling: Reference to approved indication for chronic ITP
  • Clinical guidelines: ASH 2019 ITP guidelines supporting use
  • Specialist involvement: Confirmation of hematologist consultation
  • Concomitant medications: Verification that TPO agonists are discontinued

Cost-Saving Options and Patient Support

Manufacturer Support Programs

Rigel Pharmaceuticals Patient Assistance:

  • Copay assistance for eligible commercially insured patients
  • Patient assistance program for uninsured/underinsured
  • Contact: 1-833-TAVALISSE (1-833-828-2547)

Foundation Grants

  • Patient Advocate Foundation: Copay relief grants
  • Good Days: Chronic disease fund assistance
  • HealthWell Foundation: Blood disorder grants

Georgia-Specific Resources

  • Georgians for a Healthy Future: Consumer assistance with insurance appeals
  • Georgia Legal Services: Free legal help for Medicaid/insurance issues

Frequently Asked Questions

How long does Humana prior authorization take for Tavalisse in Georgia?
Standard PA decisions are made within 7 days for Part D drugs and up to 30 days for medical benefit coverage. Expedited requests receive decisions within 72 hours.

What if Tavalisse isn't on my Humana formulary?
You can request a formulary exception by demonstrating medical necessity and showing that formulary alternatives are ineffective or contraindicated.

Can I get an expedited appeal if my platelet count is dangerously low?
Yes, if your prescriber attests that waiting for standard processing timelines would endanger your health, you can request expedited review with 72-hour decision deadlines.

Does Georgia's external review apply to Medicare Advantage plans?
No, Medicare Advantage appeals follow federal processes through Independent Review Entities. Georgia DOI external review applies to state-regulated commercial plans.

What happens if I start Tavalisse before getting approval?
You may be responsible for the full cost ($14,000+ per month). Always wait for PA approval before filling the prescription.

How do I prove that TPO receptor agonists failed?
Provide documentation showing adequate trial duration (typically 4-6 weeks), maximum tolerated doses, and clinical response (or lack thereof) with specific platelet count measurements.

When to Get Additional Help

Consider contacting Counterforce Health if you're facing repeated denials or complex appeals. Our platform helps patients, clinicians, and pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each plan's specific requirements.

For Georgia residents needing additional support:

  • Georgia DOI Consumer Services: 1-800-656-2298
  • Georgians for a Healthy Future: Consumer assistance programs
  • Patient Advocate Foundation: 1-800-532-5274

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For personalized assistance with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.