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

How to Get Tavalisse (Fostamatinib) Covered by Blue Cross Blue Shield in California: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Tavalisse Covered by Blue Cross Blue Shield in California

Tavalisse (fostamatinib) is covered by Blue Shield of California as a specialty medication requiring prior authorization and specialty pharmacy dispensing. The fastest path to approval: 1) Have your hematologist submit a prior authorization request documenting failed first-line ITP therapies (steroids, IVIG, or TPO receptor agonists), 2) Apply for the manufacturer's copay assistance program to reduce costs to $15/month, and 3) If denied, file an internal appeal within 180 days, then request an Independent Medical Review (IMR) through California's Department of Managed Health Care for binding external review.

Table of Contents

What Drives Tavalisse Costs

Tavalisse's high out-of-pocket costs stem from its specialty tier placement across Blue Cross Blue Shield plans. Blue Shield of California lists Tavalisse on their specialty drug formularies for Plus, Standard, and Performance plans, typically placing it on Tier 5 or 6.

Understanding Specialty Tier Costs

Specialty medications like Tavalisse typically involve:

  • Coinsurance: 20-30% of the drug's cost (versus flat copays for lower tiers)
  • High deductibles: Many plans require meeting your annual deductible first
  • Monthly costs: Often $300-800+ per month without assistance

The wholesale acquisition cost for Tavalisse ranges from approximately $14,000-$16,000 per 60-tablet bottle, making even a 25% coinsurance substantial.

Note: Specialty tier placement reflects the medication's high cost and specialized nature, not necessarily its clinical effectiveness.

Benefit Investigation: What to Ask Your Insurer

Before starting Tavalisse, contact Blue Shield member services (number on your insurance card) to verify your specific coverage details.

Essential Questions to Ask

  1. Is Tavalisse covered on my formulary? Request the specific tier placement
  2. What prior authorization requirements apply? Ask for the PA criteria document
  3. Is step therapy required? Which medications must be tried first
  4. What's my specialty drug cost-sharing? Copay amount or coinsurance percentage
  5. Which specialty pharmacies are in-network? Confirm CVS Specialty or alternatives
  6. What's my annual out-of-pocket maximum? This caps your yearly costs

Information to Record

  • Member ID and group number
  • Formulary name and year (e.g., "2024 Commercial Plus")
  • PA reference number (if coverage is approved)
  • Representative name and call reference number
  • Specialty pharmacy contact information

Manufacturer Assistance and Foundation Programs

Multiple financial assistance options can significantly reduce your Tavalisse costs.

Rigel OneCore Copay Assistance Program

The manufacturer's copay assistance program offers the most immediate savings for commercially insured patients:

  • Reduced copay: As low as $15 per prescription fill
  • Annual benefit cap: $25,000 per calendar year
  • Eligibility: Commercial insurance only (excludes Medicare/Medicaid)
  • No income limits: Available regardless of household income
  • Enrollment: Call 1-833-744-3562 or enroll through your hematologist

Foundation Grant Programs

For patients who don't qualify for manufacturer assistance or need additional support:

HealthWell Foundation

  • Provides copay assistance for ITP patients
  • Income limit: 400% of Federal Poverty Level
  • Average grant utilization: $2,300 over 12 months
  • Requires health insurance coverage

Patient Access Network Foundation

  • Has assisted over 1.3 million patients since 2004
  • Covers copayments, coinsurance, and deductibles
  • Multiple disease-specific funds available

The Assistance Fund

  • Financial assistance for medication costs and health-related expenses
  • Case management services included
  • Multiple funding sources available
From our advocates: We've seen patients successfully combine manufacturer copay assistance with foundation grants when their annual costs exceed the manufacturer's benefit cap. Start with the copay card, then apply for foundation assistance if you approach the $25,000 limit mid-year.

Requesting Formulary Tier Exceptions

If Tavalisse is non-formulary or placed on a high-cost tier, you can request a formulary exception to move it to a lower tier.

When to Request an Exception

  • Tavalisse is not covered (non-formulary)
  • Lower-tier alternatives have failed or are contraindicated
  • You're experiencing financial hardship due to specialty tier costs

Evidence to Include

Your hematologist should submit documentation showing:

  1. Medical necessity: Why Tavalisse is clinically appropriate for your ITP
  2. Failed alternatives: Documented trials of corticosteroids, IVIG, or TPO receptor agonists
  3. Contraindications: Medical reasons other treatments aren't suitable
  4. Clinical guidelines: References to ITP treatment guidelines supporting Tavalisse use

Exception Request Process

  1. Provider submission: Your hematologist submits the exception request
  2. Review timeline: Blue Shield typically responds within 72 hours for urgent requests, 14 days for standard
  3. Appeal if denied: Follow the standard appeals process if the exception is rejected

Specialty Pharmacy Requirements

Blue Shield of California requires specialty medications like Tavalisse to be dispensed through their network specialty pharmacies.

In-Network Options

  • CVS Specialty Pharmacy: Primary specialty pharmacy partner
  • Accredo Specialty Pharmacy: Alternative network option
  • Local specialty pharmacies: Limited network options (verify coverage)

Coordination Tips

  1. Enrollment: Your provider or the specialty pharmacy will handle enrollment
  2. Prior authorization: The pharmacy coordinates PA submission with your doctor
  3. Delivery scheduling: Most specialty pharmacies offer free overnight shipping
  4. Refill reminders: Automated systems help ensure treatment continuity
  5. Clinical support: Many specialty pharmacies provide adherence monitoring
Tip: Establish your specialty pharmacy relationship before your first fill. This ensures smooth coordination and helps avoid treatment delays.

Appeals Process for Coverage Denials

If Blue Shield denies coverage for Tavalisse, California offers a robust appeals process with high success rates for medically necessary treatments.

Internal Appeals Process

Step 1: File Internal Appeal

  • Timeline: 180 days from denial notice
  • Submission: Online portal, phone, or written request
  • Required documents: Original denial letter, medical records, provider statement
  • Decision timeline: 30 days for standard appeals, 72 hours for expedited

Step 2: Escalated Internal Review

  • If first-level appeal is denied
  • Timeline: 30 days to request escalation
  • Review: Senior medical director or external physician
  • Decision timeline: 30 days for standard, 72 hours for expedited

External Review (Independent Medical Review)

If internal appeals are unsuccessful, California's Independent Medical Review (IMR) provides binding external review.

IMR Eligibility

  • Internal appeals exhausted or health plan failed to respond
  • Denial based on medical necessity, experimental/investigational determination
  • Request within 6 months of final internal denial

IMR Process

  1. Application: Submit through California Department of Managed Health Care
  2. Review: Independent physicians in relevant specialty
  3. Timeline: 45 days for standard review, 72 hours for expedited
  4. Cost: Free to patients
  5. Decision: Binding on health plan

IMR Success Rates California IMR reviews show approximately 73% success rates for specialty drug appeals when proper documentation is submitted.

Annual Renewal and Budget Planning

Tavalisse coverage requires ongoing management as insurance benefits and manufacturer programs reset annually.

Annual Renewal Checklist

Insurance Benefits (January)

  • Review new formulary for tier changes
  • Confirm specialty pharmacy network status
  • Update deductible and out-of-pocket maximum amounts
  • Verify prior authorization renewal requirements

Manufacturer Assistance (January)

  • Re-enroll in Rigel OneCore copay assistance program
  • Update income documentation if required
  • Confirm benefit cap reset ($25,000 annual limit)

Prior Authorization Renewal

  • Most PA approvals last 6-12 months
  • Request renewal 30-45 days before expiration
  • Provide updated clinical documentation showing continued medical necessity

Budget Planning Tips

  1. Calculate annual costs: Factor in deductible, coinsurance, and out-of-pocket maximum
  2. Plan for gaps: Consider coverage gaps during plan transitions
  3. HSA/FSA planning: Use tax-advantaged accounts for out-of-pocket costs
  4. Foundation backup: Apply for grants early in the year when funds are available

Phone Scripts for Common Situations

Calling Blue Shield Member Services

"Hi, I'm calling to verify coverage for Tavalisse, spelled T-A-V-A-L-I-S-S-E, for chronic ITP. My member ID is [number]. Can you tell me if this medication is on my formulary, what tier it's on, and what prior authorization requirements apply? I also need to know my specialty drug cost-sharing and which specialty pharmacies are in-network."

Requesting Expedited Appeal

"I need to request an expedited appeal for Tavalisse coverage. My doctor has documented that this medication is medically necessary for my chronic ITP, and I've failed standard treatments including [list treatments]. The delay in treatment is causing my platelet count to remain dangerously low. Can you please process this as an urgent medical review?"

Specialty Pharmacy Enrollment

"I need to transfer my Tavalisse prescription to your specialty pharmacy. My doctor is [name], and the prescription was originally sent to [current pharmacy]. I have Blue Shield of California insurance, and I understand you're in-network for specialty medications. Can you help coordinate the transfer and prior authorization?"

Counterforce Health helps patients navigate complex prior authorization requirements and appeals processes for specialty medications like Tavalisse. Our platform analyzes denial letters and creates targeted, evidence-based appeals that align with payer-specific requirements, significantly improving approval rates for medically necessary treatments.

FAQ

How long does Blue Shield prior authorization take for Tavalisse in California? Standard PA requests typically receive decisions within 72 hours to 14 days. Urgent requests (when medically necessary) must be decided within 72 hours per California regulations.

What if Tavalisse is not on my Blue Shield formulary? You can request a formulary exception with documentation of medical necessity and failed alternatives. If denied, appeal through internal review and then California's Independent Medical Review process.

Can I get expedited appeals for Tavalisse in California? Yes, if your hematologist documents medical urgency (e.g., dangerously low platelet counts), you can request expedited review with 72-hour decision timelines at both internal and IMR levels.

Does the Tavalisse copay card work with all Blue Shield plans? The copay assistance program works with commercial Blue Shield plans but excludes government-funded insurance (Medicare, Medicaid). Contact Rigel OneCore at 1-833-744-3562 to verify eligibility.

What happens if I reach the $25,000 annual copay card limit? Once you reach the annual benefit cap, you'll pay your plan's standard cost-sharing. Apply for foundation grants early in the year as backup funding, and consider using HSA/FSA funds for remaining costs.

How often do I need prior authorization renewal for Tavalisse? PA approvals typically last 6-12 months depending on your specific Blue Shield plan. Your specialty pharmacy will coordinate renewal requests 30-45 days before expiration.

What clinical documentation helps ensure Tavalisse approval? Key documentation includes: confirmed ITP diagnosis with ICD-10 code D69.3, documented platelet counts, records of failed first-line therapies (corticosteroids, IVIG), contraindications to alternatives, and hematologist attestation of medical necessity.

Can I appeal Blue Shield denials to California state regulators? Yes, after exhausting internal appeals, you can request Independent Medical Review through the California Department of Managed Health Care. This external review is binding on Blue Shield and free to patients.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies vary by specific Blue Shield plan and individual circumstances. Always verify current coverage details with your insurance plan and consult your healthcare provider for medical decisions. For personalized assistance with prior authorizations and appeals, Counterforce Health provides specialized support for patients navigating insurance coverage challenges for specialty medications.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.