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

How to Get Tavalisse (fostamatinib) Covered by Blue Cross Blue Shield in Florida: Complete Guide to Prior Authorization, Appeals, and Cost Reduction

Answer Box: Getting Tavalisse Covered by Florida Blue Cross Blue Shield

Fastest path to approval: Florida Blue requires prior authorization for Tavalisse (fostamatinib) for chronic ITP patients. You'll need documented failure of corticosteroids and typically a TPO receptor agonist, plus prescription by a hematologist. Start with your doctor's office submitting a complete PA request through CoverMyMeds or Florida Blue's provider portal. If denied, file an internal appeal within 180 days, then external review through Florida's Department of Financial Services if needed. Expect 72 hours for standard PA decisions, 24 hours for expedited requests when medically urgent.

First step today: Call the member services number on your Florida Blue ID card and ask: "What are the exact prior authorization criteria for Tavalisse (fostamatinib) under my plan, and is it covered under pharmacy or medical benefits?"

Table of Contents

  1. Understanding Florida Blue's Coverage for Tavalisse
  2. Prior Authorization Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Cost Reduction Strategies
  6. Appeals Process in Florida
  7. Patient Assistance Programs
  8. FAQ: Tavalisse Coverage Questions
  9. When to Escalate to State Regulators

Understanding Florida Blue's Coverage for Tavalisse

Florida Blue (Blue Cross Blue Shield of Florida) covers Tavalisse for adults with chronic immune thrombocytopenia (ITP), but it's classified as a high-cost specialty medication requiring prior authorization. The drug typically appears on a specialty tier rather than generic or preferred brand tiers, meaning higher out-of-pocket costs.

Coverage at a Glance

Requirement What it means Where to find it
Prior Authorization Required for all plans Florida Blue Medical Guidelines
Formulary Status Specialty tier (varies by plan) Member portal
Step Therapy Usually requires TPO-RA failure Plan-specific PA criteria
Prescriber Requirement Hematologist or ITP specialist Prior authorization form
Diagnosis Code ICD-10 D69.3 (chronic ITP) Medical records
Appeals Deadline 180 days from denial Florida Blue policy

Prior Authorization Requirements

Florida Blue's prior authorization criteria for Tavalisse align closely with FDA labeling and standard ITP treatment guidelines. Here's what your hematologist needs to document:

Clinical Criteria Checklist

Patient Requirements:

  • Age 18 or older
  • Confirmed diagnosis of chronic ITP (≥12 months duration)
  • Platelet count <30,000/µL or <50,000/µL with bleeding risk
  • ICD-10 code D69.3 documented

Prior Therapy Documentation:

  • Inadequate response to corticosteroids (prednisone, dexamethasone)
  • Trial of at least one thrombopoietin receptor agonist (eltrombopag or romiplostim) with failure, intolerance, or contraindication
  • Documentation of why splenectomy isn't appropriate (if applicable)

Prescriber Requirements:

  • Prescription by hematologist or physician experienced in ITP management
  • Recent clinic notes supporting diagnosis and treatment rationale
Tip: Florida Blue processes most specialty drug PAs through their pharmacy benefit manager, Prime Therapeutics. Your doctor's office should use the Prime PA portal or CoverMyMeds for fastest processing.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage Details

Who does it: Patient
Action: Call member services and ask for Tavalisse's formulary status, tier, and PA requirements
Timeline: 10-15 minutes
Document: Write down the specific criteria mentioned

2. Gather Required Documentation

Who does it: Patient and clinic
Action: Collect platelet counts, prior therapy records, and specialist notes
Timeline: 1-2 days
Forms needed: Complete medical history for ITP

3. Submit Prior Authorization

Who does it: Prescribing physician
Action: Complete PA request through CoverMyMeds or Prime Therapeutics portal
Timeline: Same day submission possible
Required attachments: Clinical notes, lab results, prior therapy documentation

4. Follow Up on Decision

Who does it: Patient or clinic
Action: Check status after 72 hours (24 hours if expedited)
Timeline: 3-5 business days typical
Next step: If approved, coordinate with specialty pharmacy; if denied, prepare appeal

5. Appeal if Denied

Who does it: Patient, prescriber, or authorized representative
Action: Submit internal appeal with additional clinical justification
Timeline: File within 180 days of denial
Forms: Florida Blue appeal forms

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Prior therapies not tried" Document specific failures Clinic notes with dates, doses, outcomes of steroids and TPO-RAs
"Not prescribed by specialist" Confirm hematologist credentials Include prescriber's CV or board certification
"Insufficient platelet count documentation" Provide recent lab values Labs within 30 days showing counts <30,000/µL
"Diagnosis not confirmed" Strengthen ITP diagnosis Bone marrow biopsy results, exclusion of other causes
"Dose exceeds guidelines" Justify higher dose Clinical rationale for exceeding 300mg daily maximum
From our advocates: We've seen Florida Blue approvals improve significantly when the hematologist includes a detailed timeline of prior treatments with specific dates, doses, and measurable outcomes like platelet counts and bleeding episodes. This creates a clear medical necessity narrative that reviewers can easily follow.

Cost Reduction Strategies

Manufacturer Copay Assistance

Rigel Pharmaceuticals offers a copay assistance program through Rigel OneCare that can reduce your out-of-pocket cost to as little as $15 per month for commercially insured patients.

Eligibility Requirements:

  • Commercial (private) insurance that covers Tavalisse
  • U.S. resident
  • Not using Medicare, Medicaid, or other government programs
  • Valid prescription from licensed prescriber

Annual Program Limits: Most manufacturer programs cap assistance at $10,000-$15,000 per year (verify current limits with program).

Formulary Tier Exceptions

If Tavalisse is on a high specialty tier, you can request a tier exception to lower your copay. Use Florida Blue's Protocol Exemption form and include:

  • Documentation that lower-tier alternatives failed or are contraindicated
  • Clinical rationale for why Tavalisse is medically necessary
  • Comparative effectiveness evidence

Specialty Pharmacy Coordination

Florida Blue often requires specialty medications like Tavalisse to be dispensed through designated specialty pharmacies. Confirm which pharmacy your plan requires and coordinate directly with them for:

  • Prior authorization status updates
  • Copay assistance program enrollment
  • Refill timing and adherence support

Appeals Process in Florida

Internal Appeal (Level 1)

Timeline: File within 180 days of denial
Decision timeframe: 30 days standard, 72 hours expedited
How to file: Florida Blue member portal or written request
Required: Denial letter, additional clinical evidence, prescriber letter of medical necessity

External Review (Level 2)

Timeline: File within 4 months after final internal denial
Decision timeframe: 45 days standard, 72 hours expedited
How to file: Florida Department of Financial Services
Cost: Free to consumer
Scope: Independent medical expert reviews medical necessity

Expedited Appeals

Available when delay would seriously jeopardize life, health, or ability to regain maximum function. Both internal and external expedited appeals are available in Florida.

Documentation for expedited requests:

  • Physician statement of urgency
  • Clinical evidence of potential harm from delay
  • Current treatment status and timeline needs

Patient Assistance Programs

Disease-Specific Foundations

Platelet Disorder Support Association (PDSA)
Provides educational resources and can help connect patients with financial assistance programs. Visit pdsa.org for current programs.

National Organization for Rare Disorders (NORD)
Offers patient assistance programs for rare disease medications. Check eligibility at their patient assistance database.

State and Federal Resources

Florida Medicaid
If you qualify based on income, Florida Medicaid may cover Tavalisse with prior authorization. Apply through ACCESS Florida.

Medicare Extra Help
For Medicare beneficiaries, the Extra Help program can reduce prescription drug costs. Apply through Social Security Administration.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific denial letter, plan policy, and clinical situation. Their platform helps patients and clinicians draft evidence-backed appeals that address the exact reasons for denial, potentially saving months of back-and-forth with insurers. Learn more at www.counterforcehealth.org.

FAQ: Tavalisse Coverage Questions

How long does Florida Blue prior authorization take?
Standard requests: 72 hours once complete clinical information is received. Expedited requests for urgent cases: 24 hours.

What if Tavalisse is non-formulary on my plan?
You can request a formulary exception using Florida Blue's coverage exception process. Include documentation that formulary alternatives failed or are contraindicated.

Can I get an expedited appeal if I'm already on Tavalisse?
Yes, if stopping treatment would cause serious harm. Your hematologist must document the medical urgency and potential consequences of treatment interruption.

Does step therapy apply if I failed treatments in another state?
Yes, documented treatment failures from other states should count toward Florida Blue's step therapy requirements. Include complete medical records from previous providers.

What's the difference between medical and pharmacy benefit coverage?
Tavalisse is typically covered under the pharmacy benefit as an oral specialty medication. This affects which forms to use and how appeals are processed.

How much will Tavalisse cost with Florida Blue?
Costs vary by plan design. Specialty tiers often require 20-50% coinsurance rather than flat copays. Use the member portal to get your specific cost estimate.

When to Escalate to State Regulators

Contact Florida's Division of Consumer Services if:

  • Florida Blue doesn't respond within required timeframes
  • You believe the denial violates Florida insurance law
  • The appeal process isn't being followed properly

Florida Insurance Consumer Helpline: 1-877-693-5236
Online complaint: MyFloridaCFO.com

What to include in your complaint:

  • Detailed timeline of events
  • Copies of all correspondence
  • Denial letters and appeal responses
  • Documentation of policy violations

When dealing with complex coverage issues for specialty medications like Tavalisse, Counterforce Health can help streamline the appeals process by analyzing your specific situation and drafting targeted responses that address payer requirements while leveraging the strongest clinical evidence for your case.

Sources & Further Reading

Disclaimer: This guide is for educational purposes only and does not constitute medical advice. Coverage policies and requirements can change. Always verify current information with your insurance plan and healthcare providers. For personalized assistance with insurance coverage issues, consult with your healthcare team or consider working with a patient advocate.

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