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

How to Get Tavalisse (Fostamatinib) Covered by Aetna CVS Health in Washington: Forms, Appeals & Contact Guide

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

Aetna CVS Health requires prior authorization for Tavalisse (fostamatinib) in Washington, with standard criteria including prior failures of corticosteroids, IVIG, and TPO agonists. Submit PA requests via your provider portal or fax to CVS Specialty at 1-800-323-2445. If denied, you have 180 days to appeal internally, followed by external review through Washington's Office of the Insurance Commissioner (OIC) at 1-800-562-6900. Start today: Call the number on your Aetna ID card to request the current PA form and verify your plan's specific requirements.

Table of Contents

  1. Verify Your Plan and Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Contact Numbers and Fax Addresses
  5. CVS Specialty Pharmacy Enrollment
  6. Appeal Process and Deadlines
  7. Washington State External Review
  8. Common Denial Reasons and Solutions
  9. Cost Assistance Programs
  10. FAQ

Verify Your Plan and Coverage

Before starting the prior authorization process, confirm your specific Aetna CVS Health plan details. Tavalisse is typically placed on Tier 5 (highest cost-sharing) with quantity limits of 2 tablets per day on most Aetna formularies.

What to check:

  • Log into your Aetna member portal at aetna.com
  • Review your 2024-2025 formulary for Tavalisse coverage tier
  • Verify if CVS Specialty is your required specialty pharmacy network
  • Check for any plan-specific step therapy requirements
Note: Washington state law mandates coverage for medically necessary FDA-approved drugs but allows insurers to implement prior authorization and step therapy protocols.

Prior Authorization Forms and Requirements

Coverage Criteria for Tavalisse

Based on comparable payer policies and Aetna's standard ITP guidelines, expect these requirements:

Requirement Details Documentation Needed
Diagnosis Chronic immune thrombocytopenia (ITP) ICD-10 code, hematologist notes
Prior Failures Corticosteroids (≥4 days), IVIG, TPO agonists (60+ days) Treatment records, response documentation
Lab Values Platelet count <30,000/μL or 30-50k with bleeding risk Recent CBC with differential
Prescriber Hematologist or oncologist preferred Provider credentials, NPI
Dosing FDA-approved dosing (100-150mg BID) Prescription details

Required Documentation Checklist

For initial approval (6-12 months):

  • ✓ Complete medical history with ITP diagnosis
  • ✓ Documentation of prior therapy failures or contraindications
  • ✓ Recent platelet counts and bleeding assessments
  • ✓ Prescriber letter of medical necessity
  • ✓ Current medication list and allergies

For reauthorization (12 months):

  • ✓ Treatment response documentation
  • ✓ Updated platelet counts showing improvement
  • ✓ Continued medical necessity justification
  • ✓ Adverse event monitoring reports

Submission Portals and Methods

Primary Submission Options

  1. Aetna Provider Portal
    • Access via NaviNet or Availity
    • Upload supporting documents directly
    • Track approval status in real-time
    • Request expedited review for urgent cases
  2. CoverMyMeds Platform
    • Electronic PA submission
    • Provider enrollment: 1-866-452-5017
    • Integrates with most EHR systems
  3. Fax Submission
    • CVS Specialty: 1-800-323-2445
    • Include cover sheet with member ID and drug name
    • Request fax confirmation receipt

Rigel OneCare Enrollment

Complete the Tavalisse Enrollment Form for manufacturer support:

  • Fax: 833-397-4435
  • Phone: 833-744-3562
  • Services: Benefits verification, prior authorization assistance, patient support

Contact Numbers and Fax Addresses

Member Services

  • General Member Services: Number on your Aetna ID card
  • Pharmacy Services: 1-888-792-3862 (Mon-Fri 7AM-11PM ET)
  • Case Management: 1-877-243-2752 (24/7)

Provider Contacts

  • Provider Services: 1-800-872-3862
  • Formulary Exception Line: 1-855-582-2025
  • CVS Specialty Provider Line: 1-800-237-2767

Specialty Drug Authorization

  • CVS Specialty Fax: 1-800-323-2445
  • Prior Auth Requests: Submit via provider portal or member ID card number
  • Expedited Reviews: Request via phone for urgent cases (24-72 hour review)

CVS Specialty Pharmacy Enrollment

Step-by-Step Enrollment Process

  1. Provider Enrollment
  2. Prescription Submission
    • ePrescribe through your EHR system
    • Call 1-800-237-2767 for phone orders
    • Fax prescriptions to 1-800-323-2445
  3. Patient Options
    • Home delivery (most common)
    • Pick up at CVS/Target locations
    • Office delivery for infusion centers

Transfer from Other Pharmacies

Contact CVS Specialty at 1-800-237-2767 to coordinate transfers from retail or other specialty pharmacies. They'll handle prescription transfers and ensure continuity of therapy.

Appeal Process and Deadlines

Internal Appeals with Aetna CVS Health

Timeline: 180 days from denial notice (commercial plans) or 60 days (Medicare Part D)

Required Documents:

  • Original denial letter or EOB
  • All prior authorization documentation
  • Medical records supporting medical necessity
  • Prescriber letter addressing denial reasons
  • Completed appeal form (if required)

Submission Methods:

  • Online: Availity provider portal
  • Mail: Aetna Provider Resolution Team, PO Box 14020, Lexington, KY 40512
  • Phone: Number on denial letter or member ID card

Processing Times:

  • Standard: 30-45 business days
  • Expedited: 36-72 hours (if delay jeopardizes health)

Second-Level Internal Appeal

If your first appeal is denied, you can request a second-level review with similar timelines and requirements. This triggers an independent medical review within Aetna's system.

Washington State External Review

Independent Review Organization (IRO) Process

After exhausting internal appeals, Washington residents can request external review through the Office of the Insurance Commissioner.

Key Details:

  • Deadline: 4 months from final internal denial
  • Standard Review: 45 days for decision
  • Expedited Review: 72 hours for urgent cases
  • Cost: Typically no fee for consumers
  • Decision: Binding on Aetna CVS Health

How to Request External Review

  1. Contact the OIC: 1-800-562-6900
  2. Submit written request with:
    • Final denial letter from Aetna
    • All appeal correspondence
    • Medical records supporting necessity
    • Prescriber statement
  3. Additional Information: You have 5+ business days to submit extra documentation to the IRO

Washington OIC Consumer Assistance

The Office of the Insurance Commissioner provides free help with appeals:

  • Consumer Advocacy: 1-800-562-6900
  • Appeal guidance and template letters
  • Complaint filing for mishandled appeals
  • External review process coordination

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Step therapy not completed Document prior failures or contraindications Treatment records, adverse event notes
Not medically necessary Provide guideline support and clinical rationale Peer-reviewed studies, FDA labeling
Non-formulary status Request formulary exception Comparative effectiveness data
Quantity limits exceeded Justify dosing based on clinical response Dose escalation rationale, monitoring
Wrong prescriber specialty Transfer to hematologist/oncologist Specialist consultation notes

Clinician Corner: Medical Necessity Letter

Essential Elements:

  • Patient's complete ITP history and current status
  • Detailed prior treatment failures with specific agents and durations
  • Clinical rationale for Tavalisse based on FDA indication
  • Monitoring plan for efficacy and safety
  • Reference to FDA prescribing information

Cost Assistance Programs

Manufacturer Support

  • Rigel OneCare: 833-744-3562
  • Services: Copay assistance, patient assistance programs
  • Eligibility: Varies by insurance type and income

Additional Resources

  • Patient Access Network Foundation: Chronic ITP fund
  • HealthWell Foundation: Autoimmune and rare disease assistance
  • Washington State pharmaceutical assistance programs
From our advocates: We've seen patients successfully appeal Tavalisse denials by thoroughly documenting each prior therapy failure with specific dates, dosages, and reasons for discontinuation. The key is showing you've tried the "preferred" treatments and why they didn't work for your specific situation.

FAQ

How long does Aetna CVS Health prior authorization take in Washington? Standard PA decisions typically take 3-7 business days. Expedited reviews (for urgent cases) are processed within 24-72 hours.

What if Tavalisse is non-formulary on my plan? Request a formulary exception by calling 1-855-582-2025. Provide documentation that formulary alternatives are inappropriate or ineffective.

Can I request an expedited appeal? Yes, if the standard timeline could seriously jeopardize your health. Your doctor must certify the urgent medical need.

Does step therapy apply if I failed treatments in another state? Yes, documented treatment failures from any location should qualify. Ensure you have complete medical records from prior providers.

What happens if the external review denies coverage? The IRO decision is binding, but you can contact the Washington OIC for additional guidance or consider legal consultation.

How much does Tavalisse cost without insurance? Wholesale acquisition cost is approximately $14,000-$16,000 per 60-tablet bottle. Counterforce Health can help navigate coverage options and appeals to reduce out-of-pocket costs.

When to Contact Counterforce Health

If you're facing repeated denials or need help crafting a strong appeal, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients, clinicians, and specialty pharmacies get prescription drugs approved by identifying denial basis and drafting point-by-point rebuttals aligned to each plan's specific rules.

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 plan and change over time. Always verify current information with Aetna CVS Health and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

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