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

How to Get Tavalisse (fostamatinib) Covered by Aetna CVS Health in New Jersey: Complete Appeals Guide

Answer Box: Fast Track to Tavalisse Coverage

Aetna CVS Health requires prior authorization for Tavalisse (fostamatinib) in New Jersey, with initial approval typically granted for 12 weeks when medical necessity criteria are met. The fastest path: have your hematologist submit a complete PA request through Availity with documented failure of first-line therapies (corticosteroids, IVIG) and current platelet counts <50 × 10⁹/L. If denied, you have 60 days to file an internal appeal, followed by New Jersey's Independent Health Care Appeals Program (IHCAP) for external review through Maximus Federal Services.

Start today: Contact your prescribing hematologist to initiate the prior authorization process and gather documentation of prior treatment failures.

Table of Contents

Understanding Tavalisse Coverage Requirements

Tavalisse (fostamatinib disodium hexahydrate) is an oral SYK inhibitor FDA-approved for adults with chronic immune thrombocytopenia (ITP) who've had insufficient response to previous treatments. With an annual cost of approximately $168,000-$192,000, most insurance plans including Aetna CVS Health require prior authorization.

Coverage at a Glance

Requirement What It Means Documentation Needed
Prior Authorization Required for all Tavalisse prescriptions Completed PA form via Availity or fax
Diagnosis Chronic ITP (>3 months duration) ICD-10: D69.3, clinical notes
Age Restriction Adults ≥18 years only Date of birth verification
Prior Therapies Failed corticosteroids, IVIG, or TPO-RAs Treatment history with dates, outcomes
Platelet Count <50 × 10⁹/L documented Recent CBC results (within 30 days)
Prescriber Board-certified hematologist preferred NPI, specialty credentials
Initial Duration 12 weeks approval Response monitoring plan required

Prior Authorization: The First Step

Aetna processes prior authorization requests within specific timeframes: standard cases within 72 hours of receiving supporting documentation, expedited cases within 24 hours.

Step-by-Step PA Submission

  1. Gather Required Documents (Patient/Clinic)
    • Complete medical history and diagnosis confirmation
    • Laboratory results showing current platelet count
    • Documentation of prior treatment failures
    • Prescriber's medical license and specialty certification
  2. Complete PA Form (Prescribing Physician)
    • Submit through Availity provider portal (fastest method)
    • Alternative: Fax to 1-888-267-3277 for specialty drugs
    • Include ICD-10 code D69.3 for chronic ITP
  3. Submit Supporting Clinical Notes (Prescribing Physician)
    • Detailed treatment history with specific dates
    • Documentation of contraindications to alternatives
    • Current bleeding risk assessment
  4. Track Submission (Patient/Clinic)
    • Standard timeline: 72 hours for decision
    • Call 1-855-240-0535 (M-F, 8 AM-6 PM CT) for status updates
Tip: Submit PA requests at least two weeks before the planned start date to allow adequate processing time.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not completed Document failure/intolerance of required first-line therapies Treatment dates, peak platelet responses, adverse events
Non-formulary status Request formulary exception with medical necessity Clinical rationale why formulary alternatives are inappropriate
Insufficient documentation Submit complete medical records CBC trends, bleeding episodes, functional impact
Prescriber not qualified Verify hematology board certification NPI lookup, specialty credentials
Experimental/investigational Cite FDA approval and indication FDA approval letter, clinical trial data

Appeals Process: Internal to External Review

When Aetna denies your Tavalisse request, New Jersey provides a robust appeals system with specific timelines and requirements.

Internal Appeals (Levels 1-2)

Filing Deadline: 60 days from denial notice Decision Timeline:

  • Standard authorization: ≤30 calendar days
  • Expedited (health at risk): ≤72 hours

How to File:

  • Online: Aetna member portal
  • Phone: Customer service number on insurance card
  • Mail/Fax: Address provided in denial letter

Required Appeal Documents

  • Original denial letter
  • Updated medical records
  • Peer-reviewed literature supporting Tavalisse use
  • Letter of medical necessity from hematologist
Note: Request expedited review if delay in treatment could seriously jeopardize your health or ability to regain maximum function.

Medical Necessity Letter Template

Your hematologist should include these key elements in their appeal letter:

[Date]
[Aetna Medical Director]
Re: [Patient Name, DOB, Member ID]
Diagnosis: Chronic ITP (ICD-10: D69.3)

Dear Medical Director,

I request approval for Tavalisse (fostamatinib) 100 mg BID for [Patient Name], 
who meets FDA indication criteria for chronic ITP with insufficient response 
to prior treatments.

**Clinical History:**
- Chronic ITP diagnosed [date], duration >12 months
- Current platelet count: [X × 10⁹/L] on [date]
- Bleeding symptoms: [describe petechiae, purpura, epistaxis]

**Prior Treatment Failures:**
| Therapy | Dates | Peak Platelets | Outcome |
|---------|--------|----------------|---------|
| Prednisone | [dates] | [count] | Steroid-dependent, side effects |
| IVIG | [dates] | [count] | Temporary response only |
| [TPO-RA if tried] | [dates] | [count] | Inadequate response |

**Clinical Rationale:**
Patient meets ASH 2019 guidelines for second-line therapy after first-line 
failure. Tavalisse clinical trials (FIT-1, FIT-2) demonstrated 18% and 16% 
stable response rates respectively, with acceptable safety profile.

**Monitoring Plan:**
- Weekly CBC x4 weeks, then every 2-4 weeks
- Dose escalation to 150 mg BID if platelets remain <50 × 10⁹/L after 4 weeks
- Discontinuation if no response after 12 weeks per FDA labeling

Sincerely,
[Physician Name, MD]
Board-Certified Hematologist
NPI: [number]

New Jersey External Review (IHCAP)

If Aetna upholds their denial after internal appeals, New Jersey's Independent Health Care Appeals Program (IHCAP) provides binding external review.

IHCAP Process Overview

Eligibility: Must complete Aetna's internal appeal process first Filing Deadline: 60 days from final internal denial (10 days for service continuation) Administrator: Maximus Federal Services Cost: Free to patients (insurer pays all fees)

How to Submit External Appeal

  1. Gather Required Documents
    • Final denial letter from Aetna
    • All medical records and supporting documentation
    • Completed external review application
  2. Submit to Maximus Federal Services
    • Online portal: Contact IHCAP (verify current submission method)
    • Phone: 1-888-393-1062 for IHCAP questions
  3. Review Timeline
    • Preliminary eligibility review: 5 business days
    • Full medical review: 45 days maximum
    • Expedited review: Much shorter timeframe if delay would cause serious harm
Important: IHCAP decisions are binding on insurance companies. If reviewers find Tavalisse medically necessary, Aetna must provide coverage.

Cost Savings and Patient Support

While pursuing coverage, explore these financial assistance options:

Manufacturer Support

  • Tavalisse Savings Program: May reduce out-of-pocket costs for eligible patients
  • Patient Assistance Program: Income-based free drug program
  • Contact: Tavalisse.com patient resources

Foundation Grants

  • HealthWell Foundation
  • Patient Access Network Foundation
  • Good Days (formerly Chronic Disease Fund)

State Resources

  • New Jersey pharmaceutical assistance programs for eligible residents
  • Hospital charity care programs

When to Escalate Further

If external review fails or you encounter procedural issues, contact:

New Jersey Department of Banking and Insurance

  • Consumer Hotline: 1-800-446-7467
  • Online complaints: DOBI website
  • Issues: Coverage denials, procedural violations, claim handling problems

Federal Resources (if applicable)

  • Medicare: 1-800-MEDICARE
  • Medicaid: New Jersey Department of Human Services

FAQ

How long does Aetna prior authorization take in New Jersey? Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests are processed within 24 hours when medical urgency is documented.

What if Tavalisse is non-formulary on my plan? You can request a formulary exception through Aetna's medical exception process. Your doctor must provide clinical justification why formulary alternatives are inappropriate for your specific case.

Can I request an expedited appeal? Yes, if delay in treatment would seriously jeopardize your health or ability to regain maximum function. Your doctor must document the medical urgency in their request.

Does step therapy apply if I failed treatments outside New Jersey? Treatment failures from any location count toward step therapy requirements, provided they're properly documented in your medical records with specific dates and outcomes.

How often do external reviews succeed? Nationally, about 50% of external appeals are decided in favor of patients. Success rates are higher when appeals include comprehensive medical documentation and peer-reviewed literature support.

What happens if I start Tavalisse while appeals are pending? Some patients choose to pay out-of-pocket initially, with potential reimbursement if appeals succeed. Discuss this option with your financial advisor and healthcare team.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters, identifying specific denial reasons, and crafting targeted rebuttals aligned with each payer's own policies. For medications like Tavalisse, we pull the right clinical evidence—from FDA labeling to specialty guidelines—and weave them into appeals that meet procedural requirements while tracking deadlines and required documentation.

This article provides educational information and should not replace professional medical advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with New Jersey insurance appeals, contact the Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

Sources & Further Reading

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