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

How to Get Tavalisse Covered by UnitedHealthcare in Pennsylvania: Complete PA Guide with Forms and Appeal Scripts

Answer Box: Getting Tavalisse Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization and step therapy for Tavalisse (fostamatinib) in Pennsylvania. You need a hematologist to prescribe it, documented failure of corticosteroids and a TPO receptor agonist, and platelet counts typically below 30,000/μL. Submit via the UHC Provider Portal with complete clinical documentation. If denied, Pennsylvania's new Independent External Review program has overturned about 50% of appealed denials in 2024.

First step today: Schedule with an in-network hematologist (PCP referral required for HMO plans) and gather all prior treatment records.

Table of Contents

Plan Types & Coverage Differences

UnitedHealthcare covers Tavalisse across HMO, PPO, and EPO plans in Pennsylvania, but referral requirements and network restrictions vary significantly.

Plan Type Hematology Referral Required? Out-of-Network Coverage? Prior Authorization?
HMO Yes, from PCP Emergency only Always required
PPO No Yes, higher cost-share Always required
EPO No Emergency only Always required

Key Implications:

  • HMO members must obtain a referral from their primary care physician before seeing a hematologist
  • All plan types require the same prior authorization process and clinical documentation
  • Out-of-network specialists are only covered by PPO plans (at higher cost) or in true emergencies

Formulary Status & Requirements

Tavalisse is classified as a specialty medication requiring prior authorization on all UnitedHealthcare formularies in Pennsylvania. It's typically placed on higher tiers with step therapy requirements.

Coverage Requirements

Based on UnitedHealthcare's clinical policy, approval requires:

  • Diagnosis: Chronic immune thrombocytopenia (ITP) lasting >12 months, confirmed by hematologist
  • Platelet Count: Documented thrombocytopenia <30,000/μL (or clinical justification if higher)
  • Prior Therapy Failures: Evidence of inadequate response or intolerance to:
    • Corticosteroids (prednisone, methylprednisolone)
    • At least one thrombopoietin receptor agonist (eltrombopag or romiplostim)
  • Prescriber: Board-certified hematologist or hematology consultation documented
  • Exclusions: Rule out secondary causes (hepatitis C, HIV, drug-induced thrombocytopenia)

Prior Authorization Process

UnitedHealthcare processes Tavalisse prior authorizations through their Provider Portal with specific documentation requirements.

Required Documentation

Your hematologist must submit:

  1. Complete medical history with ICD-10 code D69.3 (chronic ITP)
  2. Laboratory results including recent CBC with platelet count and peripheral blood smear
  3. Prior treatment documentation with dates, doses, duration, and reasons for discontinuation
  4. Clinical notes supporting medical necessity and treatment goals
  5. Monitoring plan for liver function tests, blood pressure, and blood counts

Timeline and Process

  • Standard review: Up to 15 business days
  • Expedited review: 24-72 hours (requires clinical urgency documentation)
  • Submission method: UHC Provider Portal (verify current link)

Step-by-Step: Fastest Path to Approval

  1. Schedule hematology consultation (obtain PCP referral if HMO member)
  2. Gather complete treatment history including all prior ITP therapies and outcomes
  3. Obtain recent labs showing current platelet count and comprehensive metabolic panel
  4. Hematologist submits PA via UHC Provider Portal with all supporting documentation
  5. Monitor PA status through provider portal or member services
  6. If approved: Prescription routed to OptumRx specialty pharmacy
  7. If denied: Begin internal appeal process immediately
From our advocates: We've seen the strongest approvals include a detailed timeline of all prior treatments with specific reasons for failure (e.g., "inadequate platelet response after 8 weeks of prednisone 1mg/kg daily" rather than just "steroid failure"). Hematologists who reference current ASH guidelines and FDA labeling in their medical necessity letters tend to have higher approval rates.

Common Denial Reasons & Solutions

Denial Reason Solution
"Insufficient prior therapy" Document specific medications, doses, duration, and clinical response with dates
"Not prescribed by specialist" Ensure hematologist submits request or provides consultation note
"Missing clinical documentation" Submit complete CBC, peripheral smear, and treatment history
"Experimental/investigational" Reference FDA approval and clinical guidelines supporting use

When facing a denial, Counterforce Health can help turn insurance denials into targeted, evidence-backed appeals by analyzing the specific denial reasons and crafting point-by-point rebuttals aligned with your plan's own coverage policies.

Pennsylvania Appeals Process

Pennsylvania launched its Independent External Review Program in January 2024, providing a robust appeals pathway for specialty drug denials.

Internal Appeals (Required First Step)

  • Timeline: File within 180 days of denial
  • Process: Submit through UHC member portal or by mail
  • Required documents: Denial letter, additional clinical evidence, provider support letter

External Review (After Internal Appeals)

Pennsylvania's program has shown impressive results:

  • Success rate: Approximately 50% of appeals overturned in 2024
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to patients
  • Eligibility: Must complete internal appeals first and file within 4 months

How to file external review:

  1. Complete UnitedHealthcare's internal appeal process
  2. Receive "Final Adverse Benefit Determination Letter"
  3. Submit request to Pennsylvania Insurance Department within 4 months
  4. Provide all medical records and supporting documentation

For urgent cases threatening health or life, expedited external review can be requested immediately without waiting for internal appeals.

Cost-Share and Savings Options

Typical Costs

  • With insurance: Varies by plan; specialty tier copays typically $100-500+ per month
  • Without insurance: Approximately $14,000-16,000 per 60-tablet bottle

Patient Assistance Programs

  • Rigel ONECARE: Manufacturer support program offering copay assistance and patient navigation
  • Foundation grants: Various patient assistance foundations provide grants for specialty medications
  • State programs: Pennsylvania may have additional assistance programs (verify current availability)

Contact Tavalisse patient support for current assistance program details and eligibility requirements.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Pennsylvania? Standard reviews take up to 15 business days, while expedited reviews for urgent cases are completed within 24-72 hours.

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

Can I request an expedited appeal? Yes, if your health condition poses an imminent threat. Your physician must certify the urgent medical need.

Does step therapy apply if I failed treatments in another state? Yes, documented treatment failures from any location count toward step therapy requirements if properly documented.

What happens if Pennsylvania's external review overturns my denial? UnitedHealthcare must provide coverage immediately, including retroactive coverage if you paid out-of-pocket during the appeal.

How do I find an in-network hematologist? Use UnitedHealthcare's provider directory online or call member services for current in-network specialists in your area.

This guide provides educational information about insurance coverage processes and should not be considered medical advice. Always consult with your healthcare providers about treatment decisions and work with them on insurance matters. For assistance with complex appeals, Counterforce Health specializes in turning insurance denials into evidence-backed appeals that align with payer policies.

Sources & Further Reading

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