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

How to Get Tavalisse (Fostamatinib) Covered by Aetna CVS Health in Pennsylvania: Prior Authorization, Appeals & Cost Assistance

Quick Answer: Getting Tavalisse Covered by Aetna CVS Health in Pennsylvania

Aetna requires prior authorization for Tavalisse (fostamatinib) in Pennsylvania. You'll need documented failure of corticosteroids and at least one thrombopoietin receptor agonist, plus a hematologist's prescription. First step today: Have your hematologist submit a PA request with your complete treatment history and recent platelet counts. If denied, Pennsylvania's new external review program has overturned over 50% of appeals in 2024. Most approvals come through within 30-45 days when all requirements are met.

Table of Contents

What Drives Tavalisse Costs with Aetna CVS Health

Tavalisse sits on Aetna's specialty drug tier, which means higher cost-sharing than standard medications. Aetna's 2025 Specialty Drug List includes fostamatinib as a covered specialty medication, but your out-of-pocket costs depend on several factors:

Benefit Design Elements:

  • Specialty tier placement: Usually 25-40% coinsurance or $100-$250 copays per fill
  • Deductible: May apply before coverage kicks in
  • Out-of-pocket maximum: Annual limit that caps your total costs
  • Quantity limits: Typically 60 tablets per 30-day fill
Note: Specialty medications like Tavalisse must be dispensed through CVS Specialty Pharmacy, not your local pharmacy.

Investigating Your Benefits

Before starting the approval process, gather this information about your specific Aetna plan:

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before first fill Aetna member portal or ID card phone number
Specialty Tier Higher cost-sharing applies Your plan's drug formulary guide
Step Therapy Must try other drugs first PA criteria documentation
Quantity Limits Maximum pills per fill Pharmacy benefit details
Hematologist Required Specialist must prescribe PA submission requirements

What to Ask Aetna

Call the member services number on your insurance card and ask:

  • "What's my specialty tier cost-sharing for Tavalisse?"
  • "Does my plan have a separate specialty deductible?"
  • "What's my remaining deductible and out-of-pocket maximum?"
  • "Are there quantity limits on fostamatinib?"

Prior Authorization Requirements

Aetna requires prior authorization for Tavalisse in Pennsylvania. Based on current PA criteria, you must meet these requirements:

Medical Necessity Criteria

  • Age: 18 years or older
  • Diagnosis: Chronic immune thrombocytopenia (ITP) lasting ≥3 months
  • Platelet count: <30,000/µL OR <50,000/µL with bleeding risk
  • Prior therapy failures: Documented inadequate response to:
    • Corticosteroids (prednisone, dexamethasone)
    • Immunoglobulins (IVIG)
    • At least one thrombopoietin receptor agonist (eltrombopag or romiplostim)
  • Prescriber: Hematologist or hematology consultation required
  • Dose: Not exceeding 150 mg twice daily

Step-by-Step: Fastest Path to Approval

  1. Hematologist evaluation (Patient schedules): Get formal ITP diagnosis and treatment history documentation
  2. Gather documentation (Clinic): Collect platelet counts, prior therapy records, and treatment failure notes
  3. Submit PA request (Hematologist): Use Aetna provider portal or fax with complete clinical package
  4. CVS Specialty enrollment (Patient): Call 1-800-237-2767 to set up delivery and copay counseling
  5. Monitor status (Patient): Check Aetna member portal or call for decision updates
  6. Appeal if denied (Patient/Clinic): Submit additional documentation or request peer-to-peer review
  7. External review option (Patient): Use Pennsylvania's independent review if internal appeals fail

Timeline: Standard decisions typically take 30-45 days. Expedited reviews (for urgent medical situations) are decided within 72 hours.

Assistance Options

Manufacturer Support

Rigel Pharmaceuticals offers copay assistance for commercially insured patients through the Tavalisse Copay Program:

  • Eligible patients pay as little as $15 per prescription
  • Requirements: Commercial insurance (not Medicare/Medicaid), U.S. residency
  • Contact: Rigel OneCare at 1-833-744-3562
  • No income limits for the copay card program

Foundation Assistance

For uninsured or underinsured patients, Rigel OneCare also offers a patient assistance program with income-based eligibility. Contact them directly for application materials.

CVS Health Foundation

CVS Health occasionally provides grants for specialty medications through their foundation programs, though availability varies by year and condition.

Appeals Process in Pennsylvania

Pennsylvania offers one of the strongest patient appeal systems in the country. Here's your roadmap if Aetna denies coverage:

Internal Appeals with Aetna

  • Timeline: 180 days to file after denial notice
  • Standard review: 30 days for decision
  • Expedited review: 72 hours for urgent cases
  • Submit via: Aetna member portal or mail to address on denial letter

Pennsylvania External Review

Pennsylvania launched its Independent External Review Program in January 2024, with impressive results:

Success Rate: Over 50% of appeals were overturned in the program's first year, with 259 favorable decisions out of 517 total appeals filed.

Process:

  1. Complete Aetna's internal appeal first
  2. Submit external review request within 4 months at pa.gov/reviewmyclaim
  3. Pennsylvania Insurance Department assigns independent physicians to review your case
  4. Decision rendered within 45 days (72 hours for urgent cases)
  5. If approved, Aetna must cover the medication immediately

Contact for Help: Pennsylvania Insurance Department Consumer Services at 1-877-881-6388

From our advocates: We've seen Pennsylvania's external review program work especially well for specialty drug denials when patients submit comprehensive medical records showing they've tried and failed the required prior therapies. The independent physicians reviewing these cases often have more specialty knowledge than initial utilization management reviewers.

Pharmacy Choice and Coordination

CVS Specialty Requirements

Aetna requires Tavalisse to be dispensed through CVS Specialty Pharmacy:

  • Phone: 1-800-237-2767
  • Services: Clinical support, insurance coordination, home delivery
  • Supply: Typically 30-day fills with up to 3 refills

Coordination Tips

  • Enroll with CVS Specialty before your PA is approved to speed up first fill
  • Provide your copay card information during enrollment
  • Set up automatic refills and delivery to avoid gaps in therapy
  • Keep CVS Specialty updated on any insurance changes

Renewal and Budget Planning

Annual Considerations

  • PA renewals: Most approvals are for 12 months, requiring clinical response documentation
  • Formulary changes: Aetna can modify coverage mid-year with proper notice
  • Cost-sharing updates: Specialty tier amounts may change at plan renewal
  • Deductible reset: Your specialty deductible starts over each January

What Can Change

  • Prior authorization criteria may become more or less restrictive
  • Step therapy requirements could add new drugs to try first
  • Quantity limits might be adjusted based on FDA labeling updates

Conversation Scripts

Calling Aetna Member Services

"Hi, I'm calling about prior authorization for Tavalisse, generic name fostamatinib, for immune thrombocytopenia. Can you tell me the PA status for my member ID [number], what my specialty tier cost-sharing would be, and whether there are any quantity limits?"

Hematologist Office to Aetna (Peer-to-Peer)

"I'm requesting a peer-to-peer review for [patient name] who needs Tavalisse for chronic ITP. The patient has failed corticosteroids and eltrombopag with documented platelet counts below 30,000. I have clinical notes showing treatment history and current bleeding risk. When can we schedule the review?"

Patient to CVS Specialty

"I'm enrolling for Tavalisse delivery. My doctor is submitting a prior authorization to Aetna, and I have a copay card from Rigel. Can you help coordinate the approval and set up delivery once it's approved?"

FAQ

How long does Aetna prior authorization take for Tavalisse in Pennsylvania? Standard PA decisions take 30-45 days. Expedited reviews for urgent medical situations are decided within 72 hours.

What if Tavalisse is non-formulary on my Aetna plan? You can request a formulary exception by having your hematologist submit clinical documentation showing medical necessity and why formulary alternatives aren't appropriate.

Can I request an expedited appeal in Pennsylvania? Yes, both Aetna's internal appeals and Pennsylvania's external review offer expedited processes when your health is at immediate risk.

Does step therapy apply if I failed treatments in another state? Yes, documented treatment failures from other states count toward Aetna's step therapy requirements as long as you have medical records proving inadequate response or intolerance.

How much will Tavalisse cost with Aetna coverage? Costs vary by plan, but specialty tier medications typically have 25-40% coinsurance or $100-$250 copays per fill. The manufacturer copay card can reduce this to $15 for eligible patients.

What happens if my appeal is denied by Pennsylvania's external review? The external review decision is final and binding. However, you may have other options like requesting a new PA if your medical condition changes or new clinical evidence becomes available.

When Treatment Coverage Gets Complex

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by turning them into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each payer's own rules. For complex cases like Tavalisse approvals, having expert support can make the difference between a successful appeal and continued delays in accessing needed treatment.

Whether you're dealing with prior authorization requirements, step therapy protocols, or appeals processes, remember that persistence often pays off. Pennsylvania's strengthened appeal system gives patients real leverage, and with proper documentation and advocacy, many initially denied specialty medications do get approved.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for the most current coverage policies and medical guidance specific to your situation. Coverage policies and requirements may change.

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