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

How to Get Tavalisse (Fostamatinib) Covered by Blue Cross Blue Shield in New York: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Tavalisse Covered by Blue Cross Blue Shield in New York

Blue Cross Blue Shield plans in New York require prior authorization for Tavalisse (fostamatinib) with hematologist involvement and documented chronic ITP after prior therapy failures. New York's strong appeal protections give you 72 hours for urgent PA decisions and 4 months to file external appeals through the Department of Financial Services. First step today: Have your hematologist gather platelet counts, prior treatment records, and submit the PA request through your plan's provider portal, marking it urgent if bleeding risk exists.

Table of Contents

  1. Why New York State Rules Matter
  2. Prior Authorization Turnaround Standards
  3. Step Therapy Protections and Medical Exceptions
  4. Continuity of Care for Ongoing Therapy
  5. External Review and Complaint Process
  6. Practical Scripts for Appeals
  7. Coverage Requirements at a Glance
  8. Appeals Playbook for BCBS New York
  9. Common Denial Reasons and Fixes
  10. When to Escalate to State Regulators
  11. FAQ

Why New York State Rules Matter

New York's insurance laws create enforceable protections that override restrictive plan policies, especially for specialty drugs like Tavalisse. Unlike many states, New York requires insurers to honor specific timeframes for prior authorization decisions and provides robust external appeal rights through the Department of Financial Services.

For Blue Cross Blue Shield plans operating in New York—including Excellus BCBS, Empire/Anthem BCBS, and others—these state rules apply to fully insured commercial plans and many Medicaid products. Self-funded employer plans may follow similar guidelines but aren't directly regulated by New York DFS.

The key advantage: New York law limits what insurers can require in step therapy protocols and guarantees your right to independent medical review if your plan denies coverage.

Prior Authorization Turnaround Standards

Standard Prior Authorization Timeline

New York requires health plans to decide prior authorization requests within specific timeframes for specialty drugs:

  • Standard requests: 3-5 business days for most specialty drugs, up to 15 business days for complex biologics
  • Complete submissions: Include all required documentation upfront to avoid "clock resets"
  • Missing information: Plans may request additional details, which can restart the review period

Urgent Prior Authorization Requirements

For urgent cases where delay would seriously jeopardize health:

  • Decision timeframe: Within 72 hours of complete submission
  • Qualifying situations: Risk of hospitalization, rapidly progressive disease, loss of function
  • Documentation needed: Prescriber must explicitly request expedited review with clinical justification
Tip: Mark your Tavalisse PA as "urgent" if your platelet count is critically low or you have active bleeding, as treatment delays can be life-threatening.

Step Therapy Protections and Medical Exceptions

New York's step therapy laws (effective for policies renewed after January 1, 2026) provide strong override protections for chronic ITP patients:

Override Criteria

Plans must grant step therapy exceptions when:

  • Required drugs are contraindicated for the patient
  • Previous therapies proved ineffective or caused intolerance
  • The prescribed drug is not in the patient's best interest
  • Patient is stable on the current medication

Key Limitations on Step Therapy

New York prohibits insurers from:

  • Requiring more than two medications before accessing the prescribed drug
  • Mandating use of step drugs for more than 30 days without guideline support
  • Requiring repeat step therapy after an override is granted (unless 365 days have passed)

For Tavalisse Specifically

Most BCBS plans require failure or intolerance of:

  1. First-line: Corticosteroids ± IVIG
  2. Second-line: TPO receptor agonists (eltrombopag, romiplostim) and/or rituximab

Document contraindications to these alternatives (liver disease, thrombotic risk, prior severe reactions) to strengthen your override request.

Continuity of Care for Ongoing Therapy

If you're already stable on Tavalisse and your BCBS plan changes its formulary or you switch plans, New York provides transition protections:

New Member Protections

  • 30-day transition supply for non-formulary drugs during first 90 days of enrollment
  • No early refill limits during transitions
  • Right to request formulary exceptions during transition period

Mid-Year Formulary Changes

When plans remove drugs or add restrictions:

  • 30-day advance notice required for current users
  • Alternative: 30-day supply at refill plus notice of change
  • Exception process: Right to request continued coverage with medical justification
Note: These protections apply strongest to Medicare plans under CMS rules, with similar policies for many commercial BCBS products.

External Review and Complaint Process

New York's external appeal system provides binding independent review when BCBS denies coverage:

When You Can Use External Appeals

After receiving a "final adverse determination" from BCBS internal appeals for denials based on:

  • Not medically necessary
  • Experimental/investigational
  • Formulary/step therapy disputes (in some cases)

Filing Requirements

  • Deadline: 4 months from final adverse determination
  • Forms: New York External Appeal Application (provided by BCBS with denial)
  • Fee: Up to $25 (waived for financial hardship, refunded if you win)
  • Submission: Direct to NY Department of Financial Services

Decision Timeframes

  • Standard external appeals: 30 days
  • Expedited external appeals: 72 hours (24 hours for urgent drug denials)
  • Binding decision: Plan must follow external reviewer's determination

Learn more about filing external appeals at the NY Department of Financial Services website.

Practical Scripts for Appeals

Phone Script for BCBS Member Services

"I'm calling about prior authorization for Tavalisse for chronic ITP. My hematologist submitted the request [date]. Under New York law, I need to know: 1) Is this being processed as urgent given my bleeding risk? 2) What's the expected decision timeframe? 3) What specific documentation is still needed? Please reference my member ID [number] and confirm you're noting this call."

Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for Tavalisse denial [reference number]. The patient has chronic ITP with platelets consistently below 20,000 despite corticosteroids and eltrombopag failure. Current bleeding episodes require immediate access to effective therapy. Please schedule with our hematologist within 72 hours per New York urgent review requirements."

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all BCBS NY plans Excellus PA List
Hematologist Prescriber Must be prescribed by or with hematology consultation Plan-specific drug policy
Platelet Documentation Counts <30,000 or <50,000 with bleeding risk Clinical notes and lab reports
Prior Therapy Failure Steroids, IVIG, TPO-RAs tried/failed/contraindicated Treatment history documentation
Diagnosis Confirmation Chronic ITP (ICD-10: D69.3) Hematologist evaluation
Appeal Deadlines 180 days internal, 4 months external NY DFS regulations

Appeals Playbook for BCBS New York

Level 1: Internal Appeal

Timeline: 30 days for standard, 72 hours for urgent How to file: BCBS member portal or written submission Required: Denial letter, medical necessity documentation, prescriber support Outcome: Final adverse determination or approval

Level 2: External Appeal (NY DFS)

Timeline: 30 days standard, 72 hours expedited How to file: NY External Appeal Application to DFS Required: Internal appeal decision, physician letter, supporting literature Outcome: Binding decision on medical necessity

Expedited Process

Available when delay would seriously jeopardize health:

  • Request expedited internal appeal first
  • If denied, immediately file expedited external appeal
  • Physician must certify urgent medical need
  • Decisions within 24-72 hours

Common Denial Reasons and Fixes

Denial Reason How to Overturn
"Not medically necessary" Submit detailed hematologist letter with platelet trends, bleeding history, and guideline citations
"Step therapy not met" Document contraindications or failures of required drugs; cite NY step therapy protections
"Experimental/investigational" Provide FDA approval letter and established ITP treatment guidelines
"Non-formulary" Request formulary exception with medical necessity justification
"Quantity limits exceeded" Document clinical need for prescribed dose/frequency with monitoring plan

When to Escalate to State Regulators

Contact New York regulators when:

  • BCBS fails to meet required decision timeframes
  • Proper appeal procedures aren't followed
  • External appeal decisions aren't implemented
  • Pattern of inappropriate denials occurs

New York Department of Financial Services

  • Consumer hotline: Check current number on DFS website
  • Online complaints: Available through DFS portal
  • External appeals: Separate process for coverage denials

Community Health Advocates (Free assistance)

  • Helpline: 888-614-5400
  • Services: Insurance denial counseling and appeal assistance
  • Eligibility: All New York residents

FAQ

How long does BCBS prior authorization take for Tavalisse in New York?

Standard requests typically take 3-5 business days, while urgent requests must be decided within 72 hours under New York law. Incomplete submissions can restart the clock.

What if Tavalisse is non-formulary on my BCBS plan?

You can request a formulary exception with medical necessity documentation. New members get 30-day transition supplies while pursuing exceptions.

Can I request an expedited appeal for Tavalisse denial?

Yes, if your hematologist certifies that delay would seriously jeopardize your health due to bleeding risk or disease progression.

Does step therapy apply if I failed treatments outside New York?

Treatment failures from other states count toward step therapy requirements. Document all prior therapies regardless of where they occurred.

What's the strongest medical necessity argument for Tavalisse?

Chronic ITP with documented platelet counts below 30,000 (or below 50,000 with bleeding), failure/intolerance of standard therapies, and ongoing bleeding risk despite rescue treatments.

How much does the external appeal process cost?

New York charges up to $25 per external appeal, waived for financial hardship and refunded if you win the appeal.

Counterforce Health specializes in turning insurance denials into successful appeals by identifying specific denial reasons and crafting targeted, evidence-backed responses. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes for specialty medications like Tavalisse.

For additional support with your Tavalisse coverage challenge, visit Counterforce Health to learn how our platform can help streamline your appeal process with payer-specific workflows and deadline tracking.

From our advocates: We've seen BCBS New York approve Tavalisse appeals when hematologists clearly document both the severity of thrombocytopenia and specific contraindications to formulary alternatives. The key is connecting your bleeding risk directly to the inadequacy of covered options, not just showing that Tavalisse works.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. Laws and regulations may change after publication.

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