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

How to Get Tavalisse (fostamatinib) Covered by Blue Cross Blue Shield in Virginia: Complete Prior Authorization & Appeals Guide

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

Tavalisse (fostamatinib) requires prior authorization from Blue Cross Blue Shield Virginia and typically needs documented failure of first-line treatments (corticosteroids, IVIG) and TPO receptor agonists (eltrombopag/Promacta, romiplostim/Nplate) for chronic ITP. Submit PA through your hematologist with platelet counts <30,000/μL, treatment timeline, and ICD-10 code D69.3. If denied, Virginia's external review via the State Corporation Commission can overturn decisions within 45 days using Form 216-A.

First step today: Call the number on your Blue Cross Blue Shield Virginia ID card to request the current Tavalisse prior authorization form and criteria.

Table of Contents

  1. When Tavalisse Alternatives Make Sense
  2. Typical ITP Treatment Alternatives
  3. Pros and Cons: Access Considerations
  4. Formulary Exception Strategy
  5. Switching Between ITP Treatments
  6. Re-Trying for Tavalisse Later
  7. Blue Cross Blue Shield Virginia Appeals Process
  8. Cost Savings and Support Programs
  9. FAQ

When Tavalisse Alternatives Make Sense

If Blue Cross Blue Shield Virginia denies Tavalisse coverage initially, exploring formulary alternatives can be a strategic first step while preparing your appeal. This approach makes sense when:

  • You need immediate treatment and can't wait 30-60 days for an appeal
  • Your hematologist recommends trying TPO receptor agonists first (often required by insurance anyway)
  • You want to build a stronger case by documenting failure of covered alternatives
  • Cost is a primary concern and covered options have lower copays

Blue Cross Blue Shield Virginia typically covers TPO receptor agonists (eltrombopag and romiplostim) on their formulary with prior authorization, though they're often placed in higher specialty tiers requiring step therapy through corticosteroids first.

From our advocates: "We've seen patients successfully get Tavalisse approved after a 4-month trial of eltrombopag that showed inadequate platelet response. The documented failure strengthened their medical necessity case significantly."

Typical ITP Treatment Alternatives

First-Line Treatments (Usually Required First)

Corticosteroids

  • Prednisone (1-2 mg/kg daily, tapered)
  • Dexamethasone (high-dose pulses)
  • Coverage: Generally covered with minimal restrictions
  • Response rate: 70-80% initially, but many relapse

IVIG (Intravenous Immunoglobulin)

Second-Line Alternatives (TPO Receptor Agonists)

Eltrombopag (Promacta)

  • Oral medication, 25-75 mg daily
  • Formulary status: Tier 3-5 on Anthem Virginia plans with PA/QL
  • Monitoring: Weekly platelets initially, then monthly

Romiplostim (Nplate)

  • Weekly subcutaneous injection, 1-10 mcg/kg
  • Coverage: Specialty pharmacy restriction, requires PA
  • Administration: In-office or home with training

Other Covered Options

Rituximab

  • Anti-CD20 monoclonal antibody
  • Coverage: Medical benefit, requires PA
  • Response: 60-70% in chronic ITP

Pros and Cons: Access Considerations

Treatment Coverage Ease Monitoring Requirements Key Advantages Main Drawbacks
Prednisone ✓ Minimal PA Basic labs Fast onset, oral Long-term side effects
IVIG Moderate PA Platelet counts Rapid effect Temporary, expensive
Eltrombopag Higher PA Weekly → monthly labs Oral, sustained Liver monitoring needed
Romiplostim Highest PA Weekly counts Effective Injection, office visits
Tavalisse Extensive PA BP, LFTs, ANC Oral, different mechanism Diarrhea, hypertension

Testing and Monitoring Considerations

All ITP treatments require regular platelet monitoring, but specific requirements vary:

  • TPO agonists: Weekly CBC initially, then every 2-4 weeks once stable
  • Tavalisse: Monitor blood pressure, liver function tests, and absolute neutrophil count
  • All treatments: Target platelet count ≥30,000-50,000/μL to minimize bleeding risk

Formulary Exception Strategy

When to Request an Exception

Request a formulary exception for Tavalisse when:

  1. You've failed ≥2 covered alternatives with documented inadequate response
  2. You have contraindications to first-line treatments (e.g., diabetes making steroids problematic)
  3. Covered options caused intolerable side effects requiring discontinuation
  4. Your case is urgent with active bleeding and platelet count <10,000/μL

Evidence That Strengthens Your Case

Clinical Documentation Checklist:

  • ITP diagnosis with ICD-10 code D69.3
  • Bone marrow biopsy results (if performed)
  • Complete trial history with dates, doses, and platelet responses
  • Recent CBC showing platelets <30,000/μL
  • Bleeding episodes or quality of life impacts
  • Hematologist's medical necessity letter

Key Points for Medical Necessity Letter:

  • Chronic ITP duration >12 months
  • Failure of corticosteroids and ≥1 TPO agonist for ≥4 months each
  • Current platelet count and bleeding risk
  • FDA-approved indication for adults with chronic ITP after insufficient response to previous therapy

Switching Between ITP Treatments

Coordination with Your Hematologist

Switching between ITP medications requires careful coordination to avoid dangerous platelet drops:

  1. Overlap period: Usually 1-2 weeks when transitioning from TPO agonists
  2. Monitoring intensification: Weekly platelet counts during transition
  3. Rescue therapy availability: IVIG on standby if platelets drop below 10,000/μL

Pharmacy Coordination

  • Specialty pharmacy enrollment: Most ITP treatments require specialty pharmacy
  • Prior authorization transfer: New PA needed for each medication switch
  • Insurance verification: Confirm coverage before discontinuing current treatment

Counterforce Health's platform can help streamline this process by automatically identifying the specific prior authorization requirements for each medication and generating targeted appeals that address your insurance plan's exact criteria.

Re-Trying for Tavalisse Later

What to Document During Alternative Trials

Keep detailed records to strengthen future Tavalisse appeals:

Treatment Response Log:

  • Weekly platelet counts with dates
  • Bleeding episodes (type, severity, treatment required)
  • Side effects experienced
  • Quality of life impacts (fatigue, activity limitations)
  • Healthcare utilization (ER visits, transfusions)

Failure Documentation:

  • Specific reasons for discontinuation
  • Maximum tolerated doses achieved
  • Duration of adequate trial (minimum 4 months for TPO agonists)
  • Physician notes documenting inadequate response

Timing Your Tavalisse Request

The strongest time to request Tavalisse is:

  • After documenting failure of ≥2 covered alternatives
  • When bleeding risk is high despite current treatment
  • If platelet counts remain <30,000/μL on maximum tolerated doses
  • When side effects significantly impact quality of life

Blue Cross Blue Shield Virginia Appeals Process

Internal Appeals (First Level)

Timeline: Submit within 180 days of denial notice Process:

  1. Call member services number on your ID card
  2. Request appeal form and specific denial criteria
  3. Submit with additional clinical documentation
  4. Decision within 30 days (expedited: 72 hours if urgent)

External Review Through Virginia SCC

If internal appeals fail, Virginia's State Corporation Commission Bureau of Insurance provides independent review:

Eligibility: Medical necessity denials from Virginia-issued plans Timeline: Submit Form 216-A within 120 days of final internal denial Process: Independent Review Organization (IRO) decision within 45 days Contact: [email protected] or (804) 371-9915

Success Factors for External Review:

  • Complete medical records showing treatment failures
  • Current clinical guidelines supporting Tavalisse use
  • Hematologist's detailed medical necessity letter
  • Evidence of bleeding risk or quality of life impact

Cost Savings and Support Programs

Manufacturer Support

Rigel ONECARE Program

  • Copay assistance: $15 per fill for eligible patients
  • Eligibility: Commercial insurance, not government plans
  • Enrollment: Contact Rigel directly or through specialty pharmacy

Additional Resources

  • Patient Access Network (PAN) Foundation: Grants for chronic disease medications
  • HealthWell Foundation: Financial assistance for specialty drugs
  • Virginia Medicaid: Expanded coverage may be available for eligible patients

FAQ

How long does Blue Cross Blue Shield Virginia prior authorization take? Standard PA decisions are made within 5-15 business days. Expedited reviews for urgent cases are completed within 24-72 hours.

What if Tavalisse is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Non-formulary medications can be covered when medically necessary and alternatives have failed.

Can I request an expedited appeal? Yes, if your doctor certifies that waiting could seriously jeopardize your health. Virginia requires expedited reviews to be completed within 72 hours.

Does step therapy apply if I failed treatments outside Virginia? Yes, documented treatment failures from any location count toward step therapy requirements. Ensure you have complete medical records from previous providers.

What happens if I can't afford Tavalisse even with insurance coverage? Contact the manufacturer's patient assistance program and explore foundation grants. Some patients qualify for free medication through patient assistance programs.

How often do external reviews succeed for specialty drugs? While specific Virginia statistics aren't publicly available, external reviews nationwide succeed in approximately 40-50% of cases when proper documentation is provided.

This article is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. For additional help with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at (877) 310-6560.

Sources & Further Reading

Counterforce Health helps patients navigate complex prior authorization requirements by analyzing denial letters and generating evidence-based appeals tailored to each insurance plan's specific criteria. Learn more at www.counterforcehealth.org.

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