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

How to Get Tavalisse Covered by Humana in Illinois: Complete Prior Authorization Guide with Forms and Appeals

Answer Box: Getting Tavalisse Covered by Humana in Illinois

Tavalisse (fostamatinib) is typically non-formulary under Humana plans in Illinois, requiring a formulary exception plus prior authorization. You'll need: (1) A hematologist prescriber with documented ITP diagnosis and platelet count <30,000/µL, (2) Evidence of failed prior therapies including steroids and TPO receptor agonists, and (3) Submission through Humana's PA portal within 72 hours for standard or 24 hours for expedited decisions. Start by calling the number on your Humana card to confirm your plan's exact requirements.

Table of Contents

  1. Plan Types and Network Requirements
  2. Formulary Status and Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Dispensing
  5. Cost-Share Considerations
  6. Submission Process and Forms
  7. Appeals Process for Illinois
  8. Common Denial Reasons
  9. Frequently Asked Questions

Plan Types and Network Requirements

Humana operates several plan types in Illinois, each with different rules for Tavalisse coverage:

Medicare Advantage Plans: Dominate Humana's Illinois footprint and follow federal Part D regulations. These plans typically require network specialty pharmacies and have standardized appeal timelines.

Commercial Plans: Often administered through partnerships with local networks. May require primary care referrals to hematologists for HMO products.

Illinois Dual Eligible Plans (MMAI): Cover both Medicare and Medicaid benefits. Follow Illinois-specific prior authorization lists with 7-day decision requirements under new CMS rules.

Note: Always verify your exact plan type using your member ID card, as network and referral requirements vary significantly between products.

Formulary Status and Tier Placement

Coverage at a Glance

Requirement What It Means Where to Find It Source
Formulary Status Non-formulary (requires exception) Humana Drug List Tool Official formulary
Prior Authorization Required for all plans PA Search Tool Provider portal
Prescriber Requirement Hematologist preferred PA criteria documents Plan-specific
Quantity Limits 60 tablets per 30 days Dispensing limit files Pharmacy benefit
Appeals Deadline 60-65 days from denial Member materials Part D regulations

Based on research across multiple states, Tavalisse does not appear on standard Humana Medicare Advantage formularies, making it a non-formulary drug requiring both a formulary exception and prior authorization. This means:

  • No standard tier placement – if approved, it's typically placed at the highest specialty tier
  • High cost-sharing – often 25-33% coinsurance for specialty tiers
  • Medical necessity documentation required to justify coverage over formulary alternatives

Alternative agents that may be preferred on Humana formularies include TPO receptor agonists like eltrombopag (Promacta) and romiplostim (Nplate), which patients typically must try before Tavalisse approval.

Prior Authorization Requirements

Core Clinical Criteria

Humana's Tavalisse coverage policy (effective through 2025) requires:

Diagnosis Requirements:

  • Chronic immune thrombocytopenia (ITP) in adults
  • Documented platelet count <30,000/µL within 30 days
  • ICD-10 code for chronic ITP

Prescriber Requirements:

  • Board-certified hematologist or physician with documented hematology expertise
  • In-network provider for your specific Humana plan

Step Therapy Documentation:

  • Failed, inadequate response, or contraindication to at least 3 prior ITP therapies:
    • Corticosteroids (prednisone, dexamethasone)
    • IVIG or anti-D immunoglobulin
    • At least one TPO receptor agonist (eltrombopag, romiplostim)
  • Documentation must include dates, doses, duration, and reasons for discontinuation

Medical Necessity Narrative

Your hematologist must explain why formulary alternatives are inappropriate, addressing:

  • Contraindications to TPO receptor agonists
  • Liver function concerns with eltrombopag
  • Injection site issues with romiplostim
  • Bleeding risk requiring oral therapy

Specialty Pharmacy Dispensing

Tavalisse is classified as a specialty oral oncology/hematology medication requiring dispensing through Humana's contracted specialty pharmacy network. The typical cost is $14,000-$16,000 per 60-tablet bottle.

Dispensing Process

  1. PA approval must be obtained before prescription routing
  2. Prescription sent directly to designated in-network specialty pharmacy
  3. Benefits investigation conducted by specialty pharmacy
  4. Patient enrollment call within 1-2 business days of approval
  5. Home delivery coordination and copay assistance setup
Tip: Ask your prescriber to verify which specialty pharmacies are in-network for your specific Humana plan before submitting the prescription.

Cost-Share Considerations

As a non-formulary specialty drug, Tavalisse carries significant cost-sharing:

Medicare Advantage Plans:

  • Specialty tier coinsurance: typically 25-33%
  • May qualify for catastrophic coverage after reaching true out-of-pocket threshold
  • Manufacturer copay cards not applicable for Medicare

Commercial Plans:

Submission Process and Forms

Step-by-Step: Fastest Path to Approval

  1. Verify Plan Requirements (Patient)
    • Call Humana member services number on your card
    • Confirm formulary status and PA requirements
    • Document your exact plan type and network
  2. Gather Clinical Documentation (Prescriber + Patient)
    • Recent CBC showing platelet count <30,000/µL
    • Complete ITP treatment history with dates and outcomes
    • Hematologist consultation notes or credentials
    • Timeline: 1-2 business days
  3. Complete PA Forms (Prescriber)
  4. Submit Request (Prescriber)
    • Preferred: Humana provider portal
    • Alternative: Fax to number on PA form
    • Request expedited review if bleeding risk present
    • Timeline: Same day
  5. Track Decision (Patient + Prescriber)
    • Standard decisions: 72 hours
    • Expedited decisions: 24 hours
    • Follow up if no response within timeframe

Illinois-Specific Forms

For Illinois MMAI dual eligible members, use the Illinois Dual Coverage Determination Form which includes:

  • Plan ID H0336 for Illinois
  • Coverage determination phone number: 1-800-555-2546
  • Same 24/72-hour decision timelines

Appeals Process for Illinois

Internal Appeals (Redetermination)

If your initial PA is denied, you have 60-65 days from the denial date to file an appeal:

Level 1: Humana Redetermination

  • Timeline: 7 days for standard, 72 hours for expedited
  • Submit via Humana appeals portal
  • Include additional clinical documentation addressing denial reasons

External Review Rights in Illinois

Illinois provides strong external review protections under the Health Carrier External Review Act:

Timeline: Must request within 30 days of final internal denial (shorter than many states) Process: Independent Review Organization (IRO) with board-certified physician reviewer Decision Time: 5 business days after IRO receives all materials Cost: Free to consumers; insurers pay review costs

Contact for Help:

  • Illinois Department of Insurance: (877) 527-9431
  • Illinois Attorney General Health Care Helpline: (877) 305-5145
Important: Illinois has a shorter external review window than many states – don't delay filing if your internal appeal is denied.

Common Denial Reasons and Fixes

Denial Reason How to Overturn Required Documentation
Prescriber not hematologist Obtain specialist consultation Hematology consultation note with NPI
Insufficient step therapy Document all prior failures Treatment timeline with dates, doses, outcomes
Platelet count not documented Submit recent labs CBC within 30 days showing <30,000/µL
Formulary alternatives not tried Show contraindications Clinical notes explaining why TPO-RAs unsuitable
Diagnosis not confirmed Provide ICD-10 code Hematologist confirmation of chronic ITP

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements:

  • Primary diagnosis: Chronic immune thrombocytopenia (ITP)
  • Duration of disease and current platelet trends
  • Comprehensive prior treatment history:
    • Corticosteroids: specific agents, doses, duration, response
    • IVIG/anti-D: frequency, effectiveness, duration of response
    • TPO receptor agonists: which tried, reasons for failure/intolerance
  • Clinical rationale for Tavalisse:
    • Why current treatments insufficient
    • Bleeding risk assessment
    • Contraindications to alternatives
  • FDA-approved dosing plan: 100mg BID, may increase to 150mg BID
  • Monitoring plan: platelet counts, liver function, blood pressure

Supporting Guidelines:

Frequently Asked Questions

How long does Humana prior authorization take in Illinois? Standard PA decisions must be made within 72 hours, expedited within 24 hours under federal Part D rules.

What if Tavalisse is non-formulary on my plan? You'll need both a formulary exception and prior authorization. Your prescriber must demonstrate medical necessity and failure of formulary alternatives.

Can I request an expedited appeal? Yes, if your prescriber certifies that delay could seriously harm your health. This triggers 24-hour decision requirements.

Does step therapy apply if I tried medications outside Illinois? Yes, document all prior therapies regardless of where received. Include medical records showing dates, doses, and outcomes.

What happens if I'm denied after internal appeal? Illinois residents can request external review within 30 days. An independent physician reviewer will make a binding decision.

Are there financial assistance programs? Commercial plan members may qualify for Tavalisse manufacturer support. Medicare patients should explore foundation grants and state pharmaceutical assistance programs.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed, targeted rebuttals. The platform analyzes denial letters and plan policies to create point-by-point appeals that meet payer-specific requirements, pulling the right clinical evidence and procedural details to maximize approval chances.

For complex cases like Tavalisse coverage, Counterforce Health's approach includes identifying the specific denial basis – whether PA criteria, step therapy, or "not medically necessary" – and crafting responses aligned to each plan's own rules with supporting FDA labeling, peer-reviewed studies, and specialty guidelines.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan, medical history, and clinical circumstances. Always consult your healthcare provider about treatment options and work directly with your insurance plan for coverage determinations. For personalized assistance with Illinois insurance appeals, contact the Illinois Department of Insurance at (877) 527-9431.

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