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

How to Get Tavalisse (Fostamatinib) Covered by Aetna CVS Health in California: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Tavalisse Approved by Aetna CVS Health in California

Aetna CVS Health requires prior authorization for Tavalisse (fostamatinib) with strict step therapy criteria including documented failure of corticosteroids, IVIG, and TPO receptor agonists. Your fastest path: Have your hematologist submit a complete PA request via the Aetna provider portal with recent platelet counts (<30,000/μL), detailed treatment history, and medical necessity letter. If denied, California's Independent Medical Review (IMR) offers a free, binding external appeal with a 55-70% success rate for specialty drug denials. Start today by calling Aetna member services at the number on your ID card to confirm your plan's exact formulary status and PA requirements.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Understanding Your Aetna CVS Health Coverage
  4. Common Denial Reasons & How to Fix Them
  5. California Appeals Process: Your Rights
  6. Cost Management and Assistance Programs
  7. When to Escalate to California Regulators
  8. Scripts and Templates
  9. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Tavalisse prescriptions Aetna provider portal or member services Aetna Specialty Policy
Formulary Status Non-formulary (NF) specialty drug Plan-specific drug guide Aetna Standard Plan Formulary
Prescriber Must be hematologist or consultation required PA submission requirements Aetna Clinical Policy
Step Therapy Prior failure of corticosteroids, IVIG, TPO agonists Medical records and pharmacy claims Aetna Medicaid Policy
Platelet Count <30,000/μL or 30-50,000/μL with bleeding risk Recent CBC (within 30 days) Aetna Clinical Policy
Quantity Limit 60 tablets per 30 days Pharmacy benefit Aetna Quantity Limits
Appeal Deadline 180 days from denial (California) Denial letter California law

Step-by-Step: Fastest Path to Approval

1. Confirm Your Coverage Details

Who: You or your clinic staff
What: Call Aetna member services (number on ID card)
Ask for: Formulary status, PA requirements, preferred specialty pharmacy
Timeline: 10-15 minutes

2. Gather Required Documentation

Who: Your hematologist's office
What needed:

  • Recent CBC showing platelet count <30,000/μL
  • Complete treatment history (corticosteroids, IVIG, TPO agonists)
  • Documentation of failures, intolerances, or contraindications
  • Medical necessity letter citing FDA approval and ITP guidelines

3. Submit Prior Authorization

Who: Prescribing physician
How: Aetna provider portal or fax (verify current number)
Timeline: Standard review 7 days, expedited 72 hours
Required: Tavalisse PA form

4. If Denied: File Internal Appeal

Who: You or your physician
When: Within 180 days of denial
How: Written appeal with additional supporting evidence
Timeline: 30 days for standard, 5 days for expedited

5. Request California IMR if Still Denied

Who: You (patient)
How: DMHC online portal or call 888-466-2219
Cost: Free
Timeline: 45 days standard, 7 days expedited
Success rate: 55-70% for specialty drugs

Understanding Your Aetna CVS Health Coverage

Tavalisse is classified as a non-formulary specialty medication on most Aetna plans, meaning it requires prior authorization and typically carries higher cost-sharing than preferred drugs. The medication costs approximately $14,000-$16,000 per 60-tablet bottle at wholesale, making coverage approval critical for most patients.

Clinical Coverage Criteria

Aetna's specialty pharmacy clinical policy covers Tavalisse only for FDA-approved chronic immune thrombocytopenia (ITP) in adults who have had insufficient response to previous treatments.

Initial approval requires ALL of the following:

  • Diagnosis of chronic ITP
  • Prescription by or consultation with hematologist
  • Untransfused platelet count <30,000/μL OR 30-50,000/μL with symptomatic bleeding or bleeding risk factors
  • Inadequate response or intolerance to prior therapies (corticosteroids, immunoglobulins)
  • No concurrent use with TPO receptor agonists (Promacta, Nplate, Doptelet)

Approval duration: 12 weeks initially, then 3-12 months based on platelet response.

Counterforce Health helps patients navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-backed appeals tailored to each insurer's specific criteria. Our platform streamlines the process of turning insurance denials into successful approvals.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Incomplete step therapy Provide detailed pharmacy records Prescription history, physician notes documenting trials and failures
Non-specialist prescriber Add hematologist consultation Consultation notes or co-signature from board-certified hematologist
Insufficient lab values Submit recent platelet counts CBC results within 30 days showing qualifying counts
Non-formulary status Request formulary exception Medical necessity letter explaining why preferred alternatives failed
Experimental/investigational Cite FDA approval FDA label, clinical guidelines (ASH, NCCN if applicable)

Clinician Corner: Medical Necessity Letter Checklist

When writing a medical necessity letter for Tavalisse, include:

  • Patient background: Age, ITP duration, bleeding history
  • Prior treatments: Specific medications, doses, duration, outcomes
  • Current status: Recent platelet counts, bleeding symptoms, quality of life impact
  • Clinical rationale: Why Tavalisse is appropriate now
  • Guidelines support: Reference FDA labeling and published ITP management guidelines
  • Monitoring plan: Safety labs, platelet monitoring schedule

California Appeals Process: Your Rights

California offers one of the most patient-friendly appeal systems in the country. If Aetna denies your Tavalisse request, you have multiple levels of recourse.

Internal Appeals (Required First Step)

  • Timeline: File within 180 days of denial
  • Process: Submit written appeal with supporting documentation
  • Decision: 30 days standard, 5 days expedited for urgent situations
  • Cost: Free

Independent Medical Review (IMR)

California's external review process is administered by the Department of Managed Health Care (DMHC) for most health plans.

Key advantages:

  • Free to patients - no filing fees
  • Binding decisions - Aetna must comply with IMR rulings
  • High success rates - 55-70% overturn rate for specialty drug denials
  • Expert review - Independent physicians specializing in hematology review cases

How to file:

  1. Complete internal appeal first (or wait 30 days)
  2. Submit IMR application online at healthhelp.ca.gov
  3. Include all medical records, denial letters, and supporting evidence
  4. DMHC assigns case to independent review organization

Timeline for IMR Process

  • Standard: 45 days from accepted application
  • Expedited: 7 days for progressive conditions (chronic ITP qualifies)
  • Emergency: 72 hours for life-threatening situations
From our advocates: "We've seen numerous California patients successfully overturn Aetna denials for specialty ITP treatments through IMR. The key is comprehensive documentation showing medical necessity and prior treatment failures. Independent reviewers often understand the urgency of bleeding disorders better than initial utilization management."

Cost Management and Assistance Programs

Even with coverage approval, specialty tier cost-sharing can be substantial. Multiple assistance options are available to California patients.

Manufacturer Support Programs

Rigel ONECARE Patient Assistance Program

  • Copay card: As little as $15 per prescription for commercially insured patients
  • Free drug program: For uninsured or financially eligible patients
  • Eligibility: U.S. residents with commercial insurance (excludes Medicare/Medicaid)
  • Contact: 1-833-744-3562 (1-833-RIGELOC)

Foundation and State Resources

  • Patient Advocate Foundation: Copay relief for chronic conditions
  • HealthWell Foundation: Specialty drug assistance
  • California Prescription Drug Discount Program: State-sponsored savings
  • Covered California premium assistance: For marketplace plans

CVS Specialty Pharmacy Coordination

Most Aetna plans require specialty medications like Tavalisse to be filled through CVS Specialty. Benefits include:

  • Prior authorization assistance: Pharmacy helps with PA submissions
  • Copay verification: Confirms assistance program eligibility
  • Home delivery: Convenient shipping with temperature control
  • Clinical support: Pharmacist consultations and monitoring

When to Escalate to California Regulators

If Aetna fails to follow proper procedures or timelines, California regulators can intervene.

Department of Managed Health Care (DMHC)

Contact: 888-466-2219
File complaints for:

  • Missed appeal deadlines
  • Failure to provide required information
  • Improper denial of IMR requests
  • Access to care issues

California Department of Insurance (CDI)

Contact: 800-927-4357
Jurisdiction: Some PPO and indemnity plans not regulated by DMHC

Scripts and Templates

Patient Phone Script for Aetna Member Services

"Hi, I'm calling about prior authorization requirements for Tavalisse, generic name fostamatinib, for chronic ITP. My member ID is [number]. Can you tell me:

  1. Is Tavalisse covered on my specific plan?
  2. What's the formulary tier and my expected copay?
  3. What prior authorization requirements apply?
  4. Which specialty pharmacy should I use?
  5. Can you email or fax me the PA form?"

Peer-to-Peer Request Script for Clinic Staff

"I'm calling to request a peer-to-peer review for [patient name], member ID [number], regarding a Tavalisse denial. Our hematologist Dr. [name] is available [days/times] to discuss the medical necessity. The patient has chronic ITP with platelet count of [number] and has failed [list prior treatments]. When can we schedule the peer-to-peer?"

FAQ

How long does Aetna CVS Health PA take in California? Standard prior authorization decisions are made within 7 business days. Expedited reviews for urgent situations are completed within 72 hours.

What if Tavalisse is non-formulary on my plan? Request a formulary exception along with your PA. Provide medical necessity documentation explaining why preferred alternatives cannot be used.

Can I request an expedited appeal if my platelets are dangerously low? Yes. Chronic ITP with severe thrombocytopenia qualifies for expedited review. Both internal appeals (5 days) and IMR (7 days) have expedited timelines.

Does step therapy apply if I failed treatments in another state? Yes, but you must provide complete documentation of prior treatments and failures from your previous providers. Pharmacy records and physician notes are essential.

What happens if Aetna approves Tavalisse but I can't afford the copay? Contact Rigel ONECARE at 1-833-744-3562 for copay assistance. Commercial patients may qualify for as little as $15 per prescription.

How do I track my appeal status? For internal appeals, call Aetna member services. For IMR, use the DMHC online portal or call 888-466-2219.

What if my hematologist won't help with appeals? Counterforce Health specializes in helping patients and providers prepare comprehensive appeals with the right evidence and documentation to maximize approval chances.

Can I continue current treatment during appeals? California's continuity of care laws may require Aetna to continue covering your current treatment during the appeal process, especially if you're switching plans or providers.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by specific plan and change over time. Always consult with your healthcare provider about treatment decisions and verify current policy details with your insurance company. For personalized assistance with prior authorizations and appeals, consider consulting with healthcare advocacy services like Counterforce Health.

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