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

How Long Does It Take to Get Tavalisse (Fostamatinib) Approved by Blue Cross Blue Shield in Georgia? Timeline & Appeals Guide

Answer Box: Getting Tavalisse Approved in Georgia

Standard approval timeline: 2-5 business days for Blue Cross Blue Shield Georgia prior authorization requests. Expedited reviews: 24 hours for urgent cases. Tavalisse requires documentation of chronic immune thrombocytopenia (ITP) diagnosis and insufficient response to prior therapies (steroids, IVIG, TPO receptor agonists). If denied, you have 60 days for internal appeal and 60 days for external review through Georgia Department of Insurance. Start by having your hematologist submit complete clinical documentation through the BCBS provider portal.

Table of Contents

  1. What Affects Tavalisse Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Reading Results
  6. If Denied: Appeal Timelines
  7. Renewal Cycles & Reauthorization
  8. Timeline Visual & Milestones
  9. Time-Saving Tips for Faster Approval

What Affects Tavalisse Approval Timing

Several factors determine how quickly Blue Cross Blue Shield Georgia processes your Tavalisse (fostamatinib) prior authorization:

Benefit Type Impact:

  • Commercial/employer plans: Standard 2-5 business days
  • Medicare Advantage: May require additional CMS compliance checks (3-7 days)
  • Individual marketplace plans: Similar to commercial timelines

Complexity of Clinical Criteria: Tavalisse requires documentation of:

  • Confirmed chronic immune thrombocytopenia (ITP) diagnosis
  • Insufficient response to prior treatments: corticosteroids, IVIG, TPO receptor agonists (eltrombopag, romiplostim)
  • Current platelet counts and bleeding history
  • Prescriber specialty (hematology preferred)

Documentation Completeness: Complete submissions with all required elements process faster than those requiring additional information requests.

Note: Georgia law mandates 24-hour turnaround for expedited reviews when clinical urgency is documented.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Patient Information:

  • BCBS Georgia member ID and group number
  • Current diagnosis codes (ICD-10: D69.3 for chronic ITP)
  • Complete medication history with dates and outcomes

Clinical Documentation:

  • Hematologist consultation notes
  • Lab results showing platelet counts over time
  • Documentation of prior therapy failures:
    • Corticosteroids (prednisone/dexamethasone) - dates, doses, response
    • IVIG treatments - frequency, effectiveness, duration
    • TPO receptor agonists tried - specific agents, reasons for discontinuation

Prescriber Requirements:

  • Board-certified hematologist preferred
  • Complete prescriber NPI and contact information
  • Medical necessity letter detailing treatment rationale

Verification Steps

  1. Confirm current formulary status via BCBS Georgia drug list
  2. Check prior authorization requirements - Tavalisse requires PA for all BCBS Georgia plans
  3. Verify patient eligibility and active coverage

Submission to Initial Review (1-5 Days)

Georgia State Requirements

Georgia regulations require BCBS to process:

  • Standard reviews: Within 2-5 business days
  • Expedited reviews: Within 24 hours for urgent medical needs
  • Complex cases: Up to 14 business days with notification

What Reviewers Check First

Medical Necessity Criteria:

  • Appropriate ICD-10 diagnosis code (D69.3)
  • Evidence of chronic ITP (>12 months duration)
  • Platelet count documentation (typically <30,000/μL)
  • Failed prior therapies per treatment algorithm

Administrative Requirements:

  • Complete prior authorization form
  • Prescriber credentials and specialty
  • Patient demographics and coverage verification

Submission Methods

Preferred: BCBS Georgia provider portal (fastest processing) Alternative: CoverMyMeds electronic submission Backup: Fax submission (confirm current number through provider services)

Additional Information Requests (1-7 Days)

Common requests for additional documentation:

Clinical Information:

  • More detailed prior therapy documentation
  • Recent lab results or platelet counts
  • Specialist consultation notes
  • Treatment response assessments

Administrative Details:

  • Updated prescriber information
  • Corrected patient demographics
  • Missing signature or date on forms

How to Respond Quickly

  1. Respond within 24-48 hours to avoid processing delays
  2. Submit complete responses - partial information extends review time
  3. Use same submission method as original request
  4. Include reference numbers from original submission
Tip: Maintain a "PA file" with all relevant clinical documents readily available for quick responses.

Decision Window & Reading Results

Typical Outcomes

Approval: Complete coverage authorization with quantity limits and duration Partial Approval: Coverage with restrictions (dose, duration, or site of care) Denial: No coverage with specific reason codes

Understanding Approval Letters

Key Information to Note:

  • Authorization number for pharmacy reference
  • Approved quantity and days supply
  • Refill limitations
  • Expiration date for reauthorization

Coverage Duration:

  • Initial approvals: Typically 12 months
  • Renewal requirements clearly stated
  • Quantity limits (usually 60 tablets per 30 days)

If Denied: Appeal Timelines

Georgia Appeal Rights

Internal Appeal:

  • Deadline: 180 days from denial date
  • Timeline: 15-30 days for standard, 72 hours for expedited
  • Requirements: Written request with supporting documentation

External Review:

  • Deadline: 60 days from final internal denial
  • Timeline: 30 business days (72 hours if expedited)
  • Cost: Free to consumers
  • Authority: Georgia Department of Insurance (1-800-656-2298)

Appeal Documentation Strategy

Strengthen Your Case With:

  • Updated clinical notes showing continued medical necessity
  • Peer-reviewed literature supporting Tavalisse use in ITP
  • Documentation of contraindications to alternative therapies
  • Evidence of treatment response or clinical improvement

From our advocates: In our experience helping patients with ITP medication appeals, cases with comprehensive documentation of prior therapy failures and clear specialist support have significantly higher success rates. The key is painting a complete picture of why Tavalisse is the appropriate next step in this patient's treatment journey.

Renewal Cycles & Reauthorization

When to Reauthorize

Standard Timeline: Submit renewal request 30-60 days before expiration Required Documentation:

  • Treatment response assessment
  • Current platelet counts
  • Continued medical necessity
  • Any adverse events or dose adjustments

What Speeds Renewals

  • Documented clinical improvement (platelet count increases, reduced bleeding)
  • No significant adverse events
  • Continued specialist oversight
  • Compliance with monitoring requirements

Timeline Visual & Milestones

Phase Timeline Key Milestones Action Required
Preparation Day 0-2 Gather documentation Patient/Provider
Submission Day 1 Submit PA request Provider
Initial Review Day 2-5 BCBS clinical review Wait/respond to requests
Decision Day 3-7 Approval/denial issued Review determination
If Denied Day 8-187 File internal appeal Patient/Provider
External Review Day 188-247 Georgia DOI review Patient

Time-Saving Tips for Faster Approval

Portal Usage Optimization

  1. Use electronic submission whenever possible
  2. Submit during business hours for faster processing
  3. Include all attachments in single submission
  4. Follow up within 3-5 days if no acknowledgment received

Bundled Evidence Strategy

Create comprehensive submission packages:

  • Complete medical history in chronological order
  • All prior therapy documentation in one file
  • Current lab results with reference ranges
  • Specialist consultation notes with clear recommendations

Direct Specialty Routing

Work with hematology specialists familiar with ITP treatment algorithms and BCBS requirements. Experienced specialists often have:

  • Established relationships with BCBS medical directors
  • Template letters for common scenarios
  • Understanding of specific documentation requirements

Cost Considerations & Support

Manufacturer Support: Rigel Pharmaceuticals offers patient assistance programs. Contact their patient support team for copay assistance and prior authorization support.

State Resources:

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient prior therapy Document failed treatments Detailed history with dates, doses, outcomes
Non-specialist prescriber Transfer to hematologist Referral and consultation notes
Missing lab values Submit recent results Platelet counts, CBC with differential
Incomplete medical necessity Strengthen clinical rationale Updated specialist letter with guidelines

Frequently Asked Questions

How long does BCBS Georgia take for Tavalisse approval? Standard reviews: 2-5 business days. Expedited reviews: 24 hours for urgent cases.

What if Tavalisse isn't on my formulary? Submit a formulary exception request with medical necessity documentation. Alternative: appeal through internal and external review processes.

Can I get expedited review in Georgia? Yes, if clinical urgency is documented. Georgia law requires 24-hour turnaround for expedited reviews.

Do I need to try all TPO receptor agonists first? Typically yes. Document specific reasons for failure or contraindications to each agent tried.

What happens if my appeal is denied? You can request external review through Georgia Department of Insurance within 60 days. This review is binding and free.

How often do I need reauthorization? Usually annually. Submit renewal requests 30-60 days before expiration with updated clinical documentation.

Counterforce Health helps patients and providers navigate complex prior authorization and appeals processes for specialty medications like Tavalisse. Our platform analyzes denial letters, identifies specific coverage criteria, and generates targeted appeals with the right clinical evidence and regulatory citations. By turning insurance denials into strategic, evidence-backed requests, we help patients get the medications they need while reducing administrative burden on healthcare providers. Visit www.counterforcehealth.org to learn more about our coverage advocacy services.

When dealing with specialty drug approvals, having the right documentation and understanding insurer-specific requirements can make the difference between approval and denial. Counterforce Health specializes in this exact challenge, helping patients and providers build stronger cases for coverage.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and specific plan benefits. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with appeals or coverage questions, 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.