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

How to Get Tavalisse (fostamatinib) Covered by Aetna CVS Health in Texas: Complete PA Guide with Appeal Scripts

Answer Box: Getting Tavalisse Covered by Aetna CVS Health in Texas

Aetna CVS Health requires prior authorization for Tavalisse (fostamatinib) with strict step therapy requirements. You must document failure of corticosteroids, immunoglobulins, and at least one TPO receptor agonist. The prescription must come from a hematologist, and the drug must be filled at CVS Specialty Pharmacy.

Start today: Schedule a hematologist appointment to document your ITP diagnosis and prior treatment failures. Gather lab results showing platelet counts <30,000/µL (or <50,000/µL with bleeding risk). Your doctor will submit the PA request through Aetna's provider portal. If denied, Texas law guarantees your right to independent external review within 4 months.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Mandatory before first fill Aetna provider portal Aetna PA Requirements
Step Therapy Must fail corticosteroids, IVIG, 1+ TPO-RA Clinical documentation CVS Caremark Policy
Specialist Prescriber Hematologist required Provider credentials Aetna Specialty Guidelines
Diagnosis Criteria Chronic ITP ≥3 months, specific platelet thresholds Lab results, ICD-10 codes FDA Label Requirements
Pharmacy Requirement CVS Specialty only Prescription routing CVS Specialty Network
Appeals Deadline 180 days from denial (Texas) Denial letter Texas Department of Insurance

Step-by-Step: Fastest Path to Approval

1. Secure Hematology Consultation

Who does it: Patient schedules appointment
Documents needed: Insurance card, complete treatment history
Timeline: 2-4 weeks for appointment
Action: Call hematology practice and mention urgent ITP medication authorization needed

2. Gather Clinical Evidence

Who does it: Hematologist's office
Documents needed:

  • Recent CBC with platelet count
  • Documentation of failed therapies (corticosteroids, IVIG, eltrombopag/romiplostim)
  • ITP diagnosis confirmation (≥3 months duration) Timeline: 1-2 days
    Source: Aetna Clinical Criteria

3. Submit Prior Authorization Request

Who does it: Prescribing hematologist
How to submit: Aetna provider portal or fax to 1-866-249-6155
Expected timeline: 30-45 days standard, 72 hours expedited
Required elements: Diagnosis, platelet counts, prior therapy failures, medical necessity letter

4. Enroll with CVS Specialty Pharmacy

Who does it: Patient
Contact: 1-800-237-2767
Documents needed: Prescription, insurance card, copay assistance card
Timeline: Same day enrollment possible
Source: CVS Specialty Enrollment

5. Apply for Copay Assistance

Who does it: Patient
Program: Rigel ONECARE copay card
Benefit: As low as $15 per fill for commercial insurance
Eligibility: No income limits, commercial insurance required
Contact: 1-833-744-3562 or Tavalisse Support

6. Track Authorization Status

Who does it: Patient or clinic staff
Method: Aetna member portal or provider portal
Frequency: Check weekly after submission
Backup: Call Aetna member services for status updates

7. Prepare for Potential Appeal

Who does it: Patient with hematologist support
Timeline: Must file within 180 days of denial in Texas
Documents to gather: Additional clinical notes, peer-reviewed studies, guideline references
Texas resource: TDI Consumer Help

Understanding Your Costs

Aetna CVS Health Tavalisse Pricing Structure

Formulary Tier: Specialty (Tier 4 or 5)
Typical Cost-Sharing: 25-40% coinsurance or $100-$250 copay per fill
Quantity Limit: 60 tablets per 30 days (standard dosing)
Annual Cost: $168,000-$192,000 without assistance

Cost Reduction Strategies

Manufacturer Copay Card (Commercial Insurance)

  • Reduces copay to as low as $15 per fill
  • No income requirements
  • Available through Rigel ONECARE
  • Not valid for Medicare, Medicaid, or other government insurance

Patient Assistance Program (Uninsured/Underinsured)

  • Free drug program for qualifying patients
  • Income-based eligibility required
  • Application through Rigel ONECARE: 1-833-744-3562
From our advocates: "We've seen patients reduce their Tavalisse costs from over $4,000 per month to under $50 by combining the manufacturer copay card with their specialty pharmacy's coordination services. The key is applying for assistance before the first fill—it's much easier than trying to get retroactive coverage."

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Step therapy not completed" Document specific prior failures Pharmacy records, clinic notes showing inadequate response to steroids, IVIG, TPO-RA
"Not prescribed by specialist" Hematology consultation Referral from PCP, hematologist credentials verification
"Insufficient platelet count documentation" Submit recent labs CBC results showing <30,000/µL or <50,000/µL with bleeding risk
"Diagnosis not established" Confirm chronic ITP criteria Documentation of ITP duration ≥3 months, exclusion of other causes
"Experimental/investigational" Cite FDA approval FDA approval letter and indication

Appeals Process in Texas

Internal Appeal (Required First Step)

Timeline: Must file within 180 days of denial
Aetna response time: 30 days (standard), 72 hours (expedited)
How to file:

  • Online: Aetna member portal
  • Mail: Medical Exception Unit, 1300 E. Campbell Road, Richardson, TX 75081
  • Fax: 1-866-249-6155

External Review (Independent Review Organization)

When available: After internal appeal denial
Timeline: Must file within 4 months of final internal denial
Texas requirement: Binding decision within 20 days (5 days for urgent)
Cost: Paid by Aetna, no patient cost
Contact: Texas Department of Insurance IRO line: 1-866-554-4926

Required Appeal Documentation

  • Complete denial letter from Aetna
  • Medical necessity letter from hematologist
  • Lab results and treatment history
  • Peer-reviewed literature supporting Tavalisse use
  • Patient impact statement (optional but helpful)

Scripts for Success

Calling Aetna Member Services

"Hello, I'm calling about a prior authorization for Tavalisse, fostamatinib, for chronic immune thrombocytopenia. My member ID is [number]. Can you tell me the current status and what additional documentation might be needed? I'd also like to confirm the specialty pharmacy requirements and any step therapy that needs to be completed."

Hematologist Office: Requesting Peer-to-Peer Review

"We're requesting a peer-to-peer review for our patient's Tavalisse prior authorization. The patient has documented chronic ITP with platelet counts below 30,000 despite trials of prednisone, IVIG, and eltrombopag. We can provide clinical notes and lab results. When can we schedule the physician-to-physician discussion?"

CVS Specialty Enrollment Call

"I need to enroll for Tavalisse dispensing. My doctor is submitting a prior authorization to Aetna. I have the manufacturer copay card and want to set up automatic refill coordination. Can you also help me understand the expected timeline once the PA is approved?"

When to Escalate

Contact Texas Department of Insurance if:

  • Aetna doesn't respond within required timeframes
  • You're denied external review when eligible
  • You suspect the denial violates Texas insurance law

TDI Consumer Help Line: 1-800-252-3439
File a complaint: TDI Online Complaint System

Office of Public Insurance Counsel (OPIC):
Help Line: 1-877-611-6742
Services: Appeals guidance, consumer advocacy

Frequently Asked Questions

Q: How long does Aetna CVS Health PA take in Texas?
A: Standard decisions take 30-45 days. Expedited reviews (for urgent medical need) are completed within 72 hours. You can request expedited review if delay would jeopardize your health.

Q: What if Tavalisse is non-formulary on my plan?
A: You can request a formulary exception by demonstrating medical necessity and failure of preferred alternatives. The same clinical documentation applies, but emphasize why formulary drugs are inappropriate.

Q: Can I appeal if I've failed step therapy outside Texas?
A: Yes, document all prior treatment failures regardless of where they occurred. Include pharmacy records, clinic notes, and provider attestations of inadequate response or intolerance.

Q: Does the manufacturer copay card work with all Aetna plans?
A: The copay card works with commercial Aetna plans but not with Medicare Advantage, Medicaid managed care, or employer plans that specifically exclude copay card use.

Q: What happens if my appeal is denied?
A: In Texas, you can request independent external review through an IRO. This decision is binding on Aetna and must be completed within 20 days (5 days for urgent cases).

Q: Can I use a local pharmacy instead of CVS Specialty?
A: No, Aetna requires Tavalisse to be dispensed through CVS Specialty Pharmacy. This is a network requirement that cannot be waived through appeals.

Q: How often do I need to renew my prior authorization?
A: Most Tavalisse PAs require annual renewal with updated clinical documentation, including current platelet counts and treatment response assessment.

Q: What if I can't afford the copay even with assistance?
A: Contact Rigel ONECARE about their patient assistance program for uninsured/underinsured patients. Some patients may qualify for free drug through income-based criteria.

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Tavalisse. Our platform analyzes denial letters, identifies the specific coverage criteria, and generates evidence-backed appeals that address each payer's requirements. We help patients, clinicians, and specialty pharmacies navigate the prior authorization process with targeted documentation and proven appeal strategies.

For additional support with Aetna denials and appeals, visit Counterforce Health to access our specialized tools and guidance.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult your healthcare provider about treatment options and work with your insurance company to understand your specific benefits. For personalized assistance with Texas insurance appeals, contact the Texas Department of Insurance or Office of Public Insurance Counsel.

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