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

Getting Tavalisse (Fostamatinib) Covered by Cigna in California: Complete Guide to Prior Authorization and Appeals

Answer Box: Your Fastest Path to Tavalisse Coverage

To get Tavalisse (fostamatinib) covered by Cigna in California: You need documented failure of prior ITP therapies (steroids, IVIG, TPO receptor agonists), a hematologist's prescription, and current platelet counts <30,000/μL. Submit prior authorization through Cigna's provider portal or fax to 1-866-873-8279. If denied, you have 180 days to request California's Independent Medical Review (IMR) through the DMHC—a free, binding external review with a 68% success rate for specialty drugs.

First step today: Contact your hematologist to gather documentation of all prior ITP treatments and their outcomes.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible: Document Checklist
  4. If You're Possibly Eligible: Next Steps
  5. If You're Not Yet Eligible: Alternatives
  6. If Denied: California Appeal Options
  7. Coverage Requirements at a Glance
  8. Step-by-Step: Fastest Path to Approval
  9. Common Denial Reasons & How to Fix Them
  10. California's Independent Medical Review Process
  11. Cost-Saving Resources
  12. FAQ

How to Use This Guide

This guide helps California patients navigate Cigna's prior authorization process for Tavalisse (fostamatinib disodium hexahydrate), a specialty medication for chronic immune thrombocytopenia (ITP). We'll walk through eligibility requirements, documentation needs, and California's powerful appeal protections.

Important: This is not medical advice. Always work with your hematologist to determine the best treatment approach for your specific situation.

Eligibility Triage: Do You Qualify?

Answer these questions to assess your likelihood of approval:

✅ Likely Eligible if you have:

  • Confirmed chronic ITP diagnosis (>12 months duration)
  • Current platelet count <30,000/μL or bleeding symptoms
  • Documented failure of corticosteroids AND at least one other therapy (IVIG, TPO receptor agonists like eltrombopag/romiplostim)
  • Prescription from or consultation with a hematologist
  • No contraindications to fostamatinib

⚠️ Possibly Eligible if you have:

  • Chronic ITP but platelet count 30,000-50,000/μL without bleeding symptoms
  • Failed only one prior therapy (need documentation of second therapy trial)
  • Specialist consultation pending but primary care involvement only

❌ Not Yet Eligible if you have:

  • Newly diagnosed ITP (<3-12 months)
  • Haven't tried standard first-line therapies
  • No specialist involvement
  • Platelet count >50,000/μL without symptoms

If You're Likely Eligible: Document Checklist

Gather these documents before submitting your prior authorization:

Medical Records Required:

  • ITP diagnosis confirmation with ICD-10 code D69.3
  • Complete blood count (CBC) showing current platelet levels
  • Treatment history with dates, dosages, and outcomes for:
    • Corticosteroids (prednisone, dexamethasone)
    • IVIG or anti-D immunoglobulin
    • TPO receptor agonists (eltrombopag/Promacta, romiplostim/Nplate)
  • Hematologist consultation notes confirming diagnosis and treatment recommendations
  • Documentation of treatment failures (lack of response, intolerance, contraindications)

Clinical Information:

  • Bleeding symptoms or risk factors documented in medical records
  • Liver function tests and blood pressure readings (baseline monitoring)
  • Pregnancy status (if applicable—fostamatinib is pregnancy category D)

If You're Possibly Eligible: Next Steps

Work with your hematologist to:

  1. Document additional therapy trials if you've only failed one treatment
  2. Obtain current platelet counts if labs are older than 30 days
  3. Schedule specialist consultation if you haven't seen a hematologist
  4. Document bleeding symptoms or quality of life impact even with higher platelet counts

Timeline: Plan 2-4 weeks to gather additional documentation before resubmitting.

If You're Not Yet Eligible: Alternatives

Discuss these options with your hematologist:

  • Standard first-line therapies: Corticosteroids, IVIG, or TPO receptor agonists
  • Clinical trials for investigational ITP treatments
  • Compassionate use programs if you have contraindications to standard therapies
  • Formulary exception requests with detailed medical necessity documentation

If Denied: California Appeal Options

California offers some of the strongest patient appeal rights in the nation. Here's your pathway:

Internal Appeals (Required First Step)

  • Timeline: File within 180 days of denial
  • Response time: 30 days for standard, 72 hours for expedited
  • How to file: Cigna member portal or written request

Independent Medical Review (IMR)

  • When to use: After internal appeal denial or if health is in immediate danger
  • Timeline: 180 days from denial to file
  • Cost: FREE to patients
  • Success rate: 68% for specialty drug requests
  • Decision time: 45 days standard, 7 days expedited
  • How to file: DMHC online application or call 1-888-466-2219
California Advantage: IMR decisions are binding on Cigna—if you win, they must cover the treatment.

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Diagnosis Chronic ITP (>12 months) Medical records with ICD-10 D69.3
Platelet Count Typically <30,000/μL Recent CBC results
Prior Therapies Failed corticosteroids + ≥1 other treatment Treatment records with dates/outcomes
Prescriber Hematologist required Specialist consultation notes
Monitoring Liver function, blood pressure Baseline labs documented
Formulary Status Specialty tier (prior auth required) Cigna formulary lookup

Step-by-Step: Fastest Path to Approval

1. Confirm Specialty Pharmacy Network (Patient)

  • Action: Verify Tavalisse is covered through Express Scripts/Accredo
  • Timeline: Same day
  • How: Call Cigna member services or check online formulary

2. Gather Treatment History (Patient + Clinic)

  • Action: Collect records of all prior ITP therapies
  • Timeline: 3-5 business days
  • Documents: Prescription records, clinic notes, lab results

3. Hematologist Consultation (Patient)

  • Action: Ensure specialist involvement in treatment plan
  • Timeline: 1-2 weeks for appointment
  • Outcome: Medical necessity letter supporting fostamatinib

4. Submit Prior Authorization (Clinic)

  • Action: Complete Cigna PA form with full documentation
  • How: Provider portal or fax 1-866-873-8279
  • Timeline: Same day submission

5. Cigna Review Process (Automatic)

  • Timeline: 15 business days standard, 72 hours expedited
  • Possible outcomes: Approved, denied, or request for additional information

6. If Approved: Fill Prescription (Patient)

  • Action: Contact Accredo or designated specialty pharmacy
  • Timeline: 2-3 business days for delivery

7. If Denied: File Appeal (Patient + Clinic)

  • Action: Submit internal appeal with additional evidence
  • Timeline: Must file within 180 days
  • Next step: Prepare for IMR if internal appeal fails

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
"Prior therapies not documented" Submit complete treatment timeline Prescription records, clinic notes showing trial/failure
"Not prescribed by specialist" Get hematologist consultation Specialist referral and treatment recommendation
"Platelet count too high" Document bleeding symptoms or risk Clinical notes showing symptoms despite higher counts
"Alternative treatments available" Show contraindications/failures Medical records documenting why alternatives won't work
"Not medically necessary" Provide clinical evidence Published guidelines, FDA labeling, specialist attestation

California's Independent Medical Review Process

Counterforce Health helps patients navigate complex specialty drug appeals by turning insurance denials into targeted, evidence-backed requests. Their platform analyzes denial letters and plan policies to identify the exact basis for denial and crafts point-by-point rebuttals aligned to the plan's own rules.

When to Request IMR:

  • Internal appeal was denied
  • Plan failed to respond within 30 days
  • Your health is in immediate danger (can skip internal appeal)
  • Denial was based on "experimental/investigational" determination

IMR Success Factors:

  • Independent physician review: Specialists in hematology/ITP evaluate your case
  • Binding decisions: Cigna must follow IMR ruling
  • No cost to patient: California law prohibits IMR fees
  • Strong track record: Higher success rates than internal appeals

How to File:

  1. Online: DMHC IMR application
  2. Phone: 1-888-466-2219 (multilingual support)
  3. Required documents: Denial letter, medical records, prescriber statement

Cost-Saving Resources

Even with insurance coverage, Tavalisse can be expensive. Explore these options:

Manufacturer Support:

  • Rigel Cares Patient Assistance Program: Income-based free drug program
  • Commercial copay card: Up to $25,000 annual savings for eligible patients
  • Information: Contact Rigel Pharmaceuticals or ask your specialty pharmacy

Foundation Grants:

  • The Leukemia & Lymphoma Society: Patient aid program for blood disorders
  • HealthWell Foundation: Copay assistance for chronic conditions
  • National Organization for Rare Disorders (NORD): Patient assistance programs

State Programs:

  • California Prescription Drug Discount Program: Additional savings for uninsured/underinsured
  • Medi-Cal: California's Medicaid program may cover Tavalisse with proper authorization

FAQ

Q: How long does Cigna's prior authorization process take in California? A: Standard review takes up to 15 business days. Expedited reviews (for urgent medical needs) are completed within 72 hours. Source: Cigna provider manual

Q: What if Tavalisse isn't on Cigna's formulary? A: You can request a formulary exception with medical necessity documentation. Your doctor must certify that formulary alternatives are ineffective or harmful. The process follows the same prior authorization pathway.

Q: Can I request an expedited appeal if my platelets are dangerously low? A: Yes. If waiting for standard review could seriously harm your health, request expedited processing. Your hematologist must document the urgency and bleeding risk.

Q: Does California's step therapy law protect ITP patients? A: California requires insurers to have clear step therapy protocols and exception processes. If you've already failed required steps or have medical contraindications, you can request an override.

Q: What happens if I move to California from another state while on Tavalisse? A: Document your current treatment and response with your new California hematologist. Prior treatment history from other states should count toward Cigna's step therapy requirements.

Q: How much does Tavalisse cost without insurance? A: Wholesale acquisition cost is approximately $14,000-$16,000 per month. Patient assistance programs and copay cards can significantly reduce out-of-pocket costs.

Q: Can I appeal to California state regulators if IMR is denied? A: IMR decisions are generally final and binding. However, you can file a complaint with the DMHC if you believe the process was flawed or if new medical evidence emerges.

Q: What's the success rate for Tavalisse appeals in California? A: While specific drug success rates aren't published, California's IMR system has a 68% patient success rate for specialty drug requests, significantly higher than internal appeals alone.

From Our Advocates

We've seen patients initially denied for Tavalisse get approved on appeal by providing comprehensive documentation of their treatment journey. The key is showing not just what treatments failed, but why they failed and how that impacts daily life. California's IMR system levels the playing field—independent hematologists reviewing your case often understand the complexity of ITP better than insurance company reviewers.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently—always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For personalized assistance with complex appeals, Counterforce Health specializes in turning insurance denials into successful approvals through evidence-based advocacy.

Need Help? Contact the California DMHC Help Center at 1-888-466-2219 for assistance with insurance complaints and appeals. All services are free and available in multiple languages.

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