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

How to Get Tavalisse (Fostamatinib) Covered by Aetna CVS Health in Virginia: Complete Appeals Guide with Forms and Scripts

Answer Box: Fastest Path to Tavalisse Coverage

To get Tavalisse (fostamatinib) covered by Aetna CVS Health in Virginia, you'll need prior authorization showing chronic ITP diagnosis, failed prior therapies (steroids, IVIG), and hematologist involvement. Submit PA via Availity provider portal with complete clinical documentation. If denied, you have 180 days to appeal internally, then 120 days for external review through Virginia's Bureau of Insurance. Start by confirming your exact formulary status and gathering CBC trends, prior therapy records, and bleeding history documentation.

Table of Contents

  1. Understanding Your Denial Letter
  2. Common Fixable Issues
  3. Prior Authorization Requirements
  4. Step-by-Step Appeal Process
  5. Peer-to-Peer Review Strategy
  6. Virginia External Review Rights
  7. Medical Necessity Letter Template
  8. Tracking and Escalation
  9. Cost Assistance Options
  10. FAQ

Understanding Your Denial Letter

When Aetna CVS Health denies Tavalisse coverage, the denial letter contains critical information for your appeal:

Key elements to identify:

  • Denial reason code (e.g., "step therapy not completed," "non-formulary," "experimental/investigational")
  • Appeal deadline (typically 180 days for utilization review decisions)
  • Clinical contact number for peer-to-peer reviews
  • Member ID and policy details to verify exact formulary
Note: Tavalisse is managed under Aetna's specialty pharmacy benefit through CVS Caremark, requiring prior authorization on most plans.

Common Fixable Issues

Before filing an appeal, check if your denial stems from easily correctable problems:

Denial Reason How to Fix Timeline
Missing hematology consultation Submit consult notes showing specialist involvement 24-72 hours via ePA
Insufficient prior therapy documentation Provide detailed records of steroid/IVIG trials and outcomes 3-5 business days
Outdated platelet counts Submit recent CBC (within 30 days) showing <100,000/µL Same day resubmission
Wrong diagnosis codes Ensure ICD-10 D69.3 (chronic ITP) is documented Provider portal update

Prior Authorization Requirements

Aetna CVS Health requires these criteria for Tavalisse approval based on their specialty policy framework:

Clinical Requirements

  • Diagnosis: Chronic immune thrombocytopenia ≥12 months duration
  • Platelet count: <100,000/µL on multiple occasions, typically <30,000/µL for treatment
  • Specialist involvement: Prescribed by or in consultation with hematologist
  • Prior therapies: Documented failure/intolerance to:
    • Corticosteroids (prednisone, methylprednisolone)
    • Intravenous immunoglobulin (IVIG)

Documentation Needed

  • Recent CBC with differential (within 30 days)
  • Hematology consultation notes
  • Complete prior therapy history with dates, doses, responses
  • Bleeding history and risk factors
  • Current medication list

Step-by-Step Appeal Process

1. First-Level Internal Appeal

Timeline: File within 180 days of denial; Aetna decides within 45 business days (commercial plans)

How to submit:

  1. Call 1-855-240-0535 (Mon-Fri, 8am-6pm local time)
  2. Submit via Availity provider portal
  3. Fax completed appeal form with supporting documents

Required documents:

  • Original denial letter
  • Medical necessity letter from prescriber
  • Complete clinical records (CBC trends, consult notes)
  • Prior therapy documentation with outcomes

2. Expedited Appeals

For urgent medical situations where delay could seriously jeopardize health:

  • Timeline: Decision within 72 hours
  • Criteria: Active bleeding, severe thrombocytopenia with high bleeding risk
  • Attestation: Prescriber must certify urgency

Peer-to-Peer Review Strategy

Request a peer-to-peer discussion with Aetna's medical director when denied for medical necessity reasons.

How to Schedule

  1. Call the clinical contact number on your denial letter
  2. Request peer-to-peer within 1-3 business days of denial
  3. Prepare 15-minute structured discussion

Key Talking Points

  • Patient-specific factors: Why formulary alternatives failed/contraindicated
  • Bleeding risk: Document severity and impact on quality of life
  • Guideline support: Reference ASH ITP guidelines supporting SYK inhibitors as second-line therapy
  • FDA indication: Emphasize on-label use for insufficient response to prior treatment

Virginia External Review Rights

If internal appeals fail, Virginia offers robust external review protections through the State Corporation Commission Bureau of Insurance.

Eligibility and Timeline

  • When: After exhausting internal appeals or carrier fails to respond timely
  • Deadline: 120 days from final internal denial
  • Form: Form 216-A (External Review Request)
  • Cost: Free to consumers

How to File

  1. Complete Form 216-A with all required information
  2. Attach final denial letter and supporting medical records
  3. Mail to: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Decision Timeline

  • Standard review: 45 days from IRO receipt
  • Expedited review: 72 hours with Form 216-C physician certification
  • Binding: Decision is binding on Aetna CVS Health if overturned
Virginia Advantage: The state's external review process has helped many patients access specialty medications, with independent medical experts reviewing cases fresh.

Medical Necessity Letter Template

Structure for Tavalisse Appeal

Subject: Appeal of Denial for Tavalisse (fostamatinib) – Medical Necessity for Chronic ITP
Patient: [Name, DOB, Member ID]
Prescriber: [Name, NPI, specialty]

1. Clinical Summary

"The patient is a [age]-year-old adult with chronic immune thrombocytopenia (ICD-10 D69.3) diagnosed [date], with chronicity confirmed by thrombocytopenia persisting >12 months despite treatment. Recent platelet counts: [list CBC results with dates showing <30,000/µL]."

2. Prior Treatment Failures

Document each therapy systematically:

  • Corticosteroids: "[Drug, dose, dates] - resulted in [no sustained response/relapse on taper/unacceptable side effects]"
  • IVIG: "[Dose, dates] - provided only transient response, unsuitable for chronic management"
  • Other therapies: Include TPO-RAs, rituximab if tried

3. Medical Necessity Rationale

"Tavalisse is FDA-approved for adult chronic ITP patients with insufficient response to prior treatment, exactly matching this patient's situation. As a SYK inhibitor, fostamatinib offers a different mechanism from failed therapies and has demonstrated efficacy in heavily pretreated patients."

4. Request

"Given documented failure/intolerance of formulary alternatives, Tavalisse is medically necessary and appropriate. I respectfully request immediate approval."

Tracking and Escalation

Appeal Log Template

Date Action Contact Outcome Next Step Deadline
[Date] PA submitted Availity Pending Follow up [+5 days]
[Date] Denial received - Step therapy File appeal [+180 days]

When to Escalate to Virginia Regulators

Contact the Virginia Bureau of Insurance if:

  • Aetna fails to meet decision deadlines
  • Procedural violations in appeal process
  • Need guidance on external review eligibility

Consumer Services: 1-877-310-6560

Cost Assistance Options

While appealing, explore financial support:

  • Rigel Pharmaceuticals Patient Support: Tavalisse HCP services for copay assistance and prior authorization support
  • Virginia Medicaid: May cover if eligible through expanded program
  • Foundation grants: National organizations supporting ITP patients

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Tavalisse. Our platform analyzes your specific denial, identifies the exact clinical evidence needed, and drafts targeted appeals that speak directly to Aetna CVS Health's criteria. We've helped many patients in Virginia navigate the prior authorization maze and secure coverage for essential ITP treatments.

If you're struggling with repeated denials or complex appeal requirements, Counterforce Health can provide the specialized expertise needed to build a winning case, saving you time and improving your chances of approval.

FAQ

How long does Aetna CVS Health PA take in Virginia?
Standard decisions typically within 3-5 business days via ePA; urgent requests within 72 hours. Complex cases may take longer.

What if Tavalisse is non-formulary on my plan?
Request a formulary exception with comprehensive medical necessity documentation showing failure of formulary alternatives.

Can I request expedited appeal if I'm actively bleeding?
Yes, if your physician certifies that delay would seriously jeopardize your health. Mark urgent on all forms and provide clinical justification.

Does step therapy apply if I failed treatments outside Virginia?
Yes, prior therapy failures from any location count toward step therapy requirements if properly documented.

What happens if external review is denied?
The decision is binding, but you retain rights to pursue other legal remedies or explore alternative coverage options.

How much does Tavalisse cost without insurance?
Approximately $14,000-$16,000 per 60-tablet bottle based on state WAC disclosures, making coverage appeals essential.

From our advocates: We've seen many Virginia patients initially denied for Tavalisse succeed on appeal by providing detailed bleeding diaries alongside CBC trends. The combination of objective lab data with subjective quality-of-life impact often resonates with reviewers. While outcomes vary, thorough documentation consistently improves approval chances.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and review your specific insurance policy terms. Appeal procedures and timelines may vary by plan type and can change. Verify current requirements with Aetna CVS Health and Virginia regulatory authorities.

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