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

How to Get Tavalisse (Fostamatinib) Covered by Blue Cross Blue Shield Michigan: Complete Prior Authorization & Appeals Guide

Quick Answer: Getting Tavalisse Covered by BCBS Michigan

Tavalisse (fostamatinib) requires prior authorization from Blue Cross Blue Shield of Michigan for chronic immune thrombocytopenia (ITP). The fastest path to approval: ensure your hematologist documents failed prior therapies (corticosteroids, IVIG, or thrombopoietin receptor agonists), submit current platelet count labs (<30,000/μL), and use BCBS Michigan's Prior Authorization Request Form. Standard approvals take 15-30 days; if denied, you have 60 days to appeal internally and 127 days for external review through Michigan DIFS.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Coverage Basics
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Understanding Timelines
  7. If You're Asked for More Information
  8. If Your Request Is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This guide helps Michigan patients and their healthcare providers navigate the prior authorization process for Tavalisse (fostamatinib disodium hexahydrate) with Blue Cross Blue Shield of Michigan. Whether you're newly diagnosed with chronic ITP or switching from another therapy, we'll walk you through each step to maximize your chances of approval.

Who this helps:

  • Adult patients with chronic immune thrombocytopenia
  • Hematologists and primary care providers
  • Patient advocates and family members
  • Those facing initial denials who need appeal guidance

Expected outcomes: With proper documentation, most medically appropriate Tavalisse requests are approved within 15-30 days. If denied, Michigan's robust external review process provides a second chance with independent medical experts.

Before You Start: Coverage Basics

Verify Your Plan Details

Before submitting any paperwork, confirm these essential details:

Plan Type: BCBS Michigan offers multiple plan types (commercial, Medicare Advantage, Medicaid). Each has different prior authorization requirements and timelines.

Formulary Status: Tavalisse is typically placed in Tier 4 or 5 (specialty tier) on BCBS Michigan formularies, meaning higher copays but coverage is available with prior authorization.

Network Status: Ensure your prescribing physician and preferred specialty pharmacy are in-network. Tavalisse must be dispensed through BCBS Michigan's approved specialty pharmacy network.

Benefit Type: Tavalisse is usually covered under the pharmacy benefit, not medical benefit. Verify this with member services at 1-800-662-6667.

Tip: Download your current formulary from the BCBS Michigan website to confirm Tavalisse's tier placement and any quantity limits.

Gather Required Documentation

Success depends on submitting complete, compelling clinical documentation. Here's what you'll need:

Clinical Requirements Checklist

Requirement What to Include Source
Diagnosis Confirmed chronic ITP with ICD-10 code D69.3 Hematologist's notes
Platelet Count Recent labs showing <30,000/μL (or <50,000/μL with bleeding risk) Laboratory report (within 30 days)
Prior Therapies Documentation of failed/intolerant treatments Medical records with dates, doses, outcomes
Prescriber Board-certified hematologist or ITP specialist Provider credentials
Contraindications Any reasons other therapies can't be used Clinical notes

Required Prior Therapy Documentation

BCBS Michigan requires evidence of insufficient response to at least one of the following:

  • Corticosteroids (prednisone, dexamethasone) - minimum 3-month trial
  • Intravenous immunoglobulin (IVIG)
  • Thrombopoietin receptor agonists (romiplostim, eltrombopag, avatrombopag)
  • Rituximab (in some cases)
Note: Document specific dates, dosages, duration of treatment, platelet count response, and reasons for discontinuation (lack of efficacy, intolerance, contraindications).

Key Forms and Documents

  1. BCBS Michigan Prior Authorization Request Form (verify current version)
  2. Prescriber attestation letter detailing medical necessity
  3. Complete medical records for the past 12 months
  4. Laboratory reports showing platelet counts and monitoring results
  5. Insurance card and member ID information

Submit Your Prior Authorization Request

Step-by-Step Submission Process

Step 1: Complete the PA Form

  • Use BCBS Michigan's current prior authorization form
  • Include all patient demographics and insurance information
  • Attach prescriber's DEA number and NPI

Step 2: Prepare Clinical Package

  • Organize documents chronologically
  • Include a cover letter summarizing the medical necessity
  • Highlight key clinical criteria that support approval

Step 3: Submit via Preferred Method

  • Online: BCBS Michigan provider portal (fastest processing)
  • Fax: Check current fax number on the PA form
  • Mail: Use certified mail for paper submissions

Step 4: Confirm Receipt

  • Note your confirmation number
  • Request estimated decision timeline
  • Ask for the case reference number

Clean Request Packet Checklist

✓ Completed PA form with all fields filled
✓ Current insurance card copy
✓ Prescriber's medical necessity letter
✓ Recent platelet count labs (within 30 days)
✓ Prior therapy documentation with outcomes
✓ Diagnosis confirmation with ICD-10 code
✓ Provider credentials (hematology board certification)

Follow-Up and Tracking

When and How to Follow Up

Timeline for Follow-Up:

  • Day 7: Confirm receipt if no acknowledgment received
  • Day 15: Check status for standard requests
  • Day 25: Escalate if no decision rendered

What to Ask:

  • "What's the current status of PA request #[reference number]?"
  • "Are any additional documents needed?"
  • "What's the expected decision date?"
  • "Can this be expedited due to medical urgency?"

Sample Follow-Up Script

"Hello, I'm calling about prior authorization request #[number] for Tavalisse for patient [name], member ID [number]. Can you please provide the current status and let me know if any additional information is needed? If there are delays, I'd like to discuss expediting this request due to the patient's low platelet count and bleeding risk."

Understanding Timelines

Michigan-Specific Timeframes

Request Type BCBS Michigan Decision Time Your Appeal Deadline
Standard PA 15-30 calendar days 60 days from denial
Urgent/Expedited 72 hours with physician attestation 60 days from denial
Internal Appeal 30 days from complete submission 127 days for external review
External Review 56-84 days (Michigan DIFS) Final decision
Important: Michigan's external review deadline is 127 days (not the federal 120 days), giving you slightly more time to file with the Michigan Department of Insurance and Financial Services.

What Speeds vs. Slows Decisions

Speeds Up Approval:

  • Complete documentation on first submission
  • Clear medical necessity letter from hematologist
  • Well-documented prior therapy failures
  • Urgent clinical need with physician attestation

Slows Down Approval:

  • Missing clinical documentation
  • Unclear prior therapy history
  • Non-specialist prescriber
  • Incomplete insurance information

If You're Asked for More Information

Handling Medical Necessity Questions

When BCBS Michigan requests additional information, respond promptly and thoroughly:

Common Requests:

  • More detailed prior therapy documentation
  • Recent platelet count trends
  • Specialist consultation notes
  • Treatment goals and monitoring plan

Response Strategy:

  • Submit within 14 days of the request
  • Include a cover letter explaining how the new information supports approval
  • Reference specific BCBS Michigan coverage criteria
  • Consider requesting a peer-to-peer review with the medical director

Attaching Supporting Literature

Include relevant clinical evidence:

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Insufficient prior therapy Document additional failed treatments with specific outcomes
Non-specialist prescriber Obtain hematology consultation and co-signature
Missing lab values Submit recent comprehensive platelet count history
Step therapy not completed Document medical contraindications to required first-line therapies
Not medically necessary Strengthen clinical justification with guidelines and peer-reviewed evidence

Appeals Process for BCBS Michigan

Level 1: Internal Appeal (60-day deadline)

  1. Complete BCBS Michigan Member Appeal Form
  2. Include new clinical evidence addressing denial reasons
  3. Request peer-to-peer review with medical director
  4. Submit within 60 days of denial notice

Level 2: External Review (127-day deadline)

  1. File with Michigan DIFS
  2. Use Michigan's External Review Request form
  3. Independent medical experts review the case
  4. Decision is binding on BCBS Michigan
From our advocates: "We've seen many Tavalisse denials overturned on appeal when families include a detailed timeline showing exactly how each prior therapy failed—specific platelet counts before, during, and after each treatment attempt. The external review panel particularly values this chronological approach to demonstrating medical necessity."

Renewal and Re-Authorization

Planning for Continued Coverage

BCBS Michigan typically approves Tavalisse for 12-month periods with renewal required.

Renewal Documentation Needed:

  • Updated platelet count trends showing response
  • Treatment adherence records
  • Any side effects or dose adjustments
  • Continued medical necessity from hematologist
  • Evidence that treatment goals are being met

Calendar Reminders:

  • 90 days before expiration: Begin gathering renewal documentation
  • 60 days before expiration: Submit renewal request
  • 30 days before expiration: Follow up on renewal status

What Evidence to Include Next Time

Focus on demonstrating ongoing clinical benefit:

  • Platelet count improvement from baseline
  • Reduced bleeding episodes
  • Improved quality of life measures
  • Absence of serious adverse effects
  • Continued need based on ITP severity

Quick Reference Checklist

Before Submitting: □ Hematologist consultation completed
□ Prior therapy failures documented
□ Recent platelet count labs obtained
□ PA form completed and signed
□ Insurance verification current

During Review: □ Confirmation number recorded
□ Follow-up calls scheduled
□ Additional documents ready if requested
□ Peer-to-peer review considered

If Denied: □ Appeal deadline noted (60 days)
□ Denial reasons understood
□ Additional evidence gathered
□ External review option preserved (127 days)

FAQ

Q: How long does BCBS Michigan prior authorization take for Tavalisse? A: Standard requests are decided within 15-30 days. Urgent requests with physician attestation are processed within 72 hours.

Q: What if Tavalisse isn't on my formulary? A: Tavalisse is typically covered as a specialty drug (Tier 4/5). If it's non-formulary, you can request a formulary exception with the same documentation.

Q: Can I request an expedited appeal in Michigan? A: Yes, if your physician certifies that delay would seriously jeopardize your health, you can request expedited internal and external reviews with 72-hour decisions.

Q: Does step therapy apply if I failed treatments outside Michigan? A: Yes, prior therapy failures from other states count. Ensure your new Michigan provider has complete medical records documenting those treatment attempts.

Q: What specialty pharmacies does BCBS Michigan use for Tavalisse? A: BCBS Michigan contracts with specific specialty pharmacy networks. Verify your preferred pharmacy is in-network before filling the prescription.

Q: How much will Tavalisse cost with BCBS Michigan coverage? A: As a specialty tier medication, expect higher copays. Check your specific plan's specialty tier cost-sharing. Manufacturer copay assistance may be available.

When navigating insurance coverage for specialty medications like Tavalisse, having expert guidance can make all the difference. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed requests that align with each payer's specific requirements. Their platform analyzes denial letters, identifies the exact approval criteria, and drafts compelling appeals that address payer concerns with the right clinical evidence and procedural requirements.

If you're facing challenges with your Tavalisse coverage, remember that persistence and thorough documentation are key. Michigan's consumer-friendly external review process provides an important safety net, and with proper preparation, most medically appropriate requests ultimately receive approval.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical advice. Always consult with your healthcare provider about treatment decisions and work directly with your insurance company for specific coverage questions. Coverage policies and requirements may change; verify current information with official sources.

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