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

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

Quick Answer: Getting Tavalisse Covered by Cigna in New York

Tavalisse (fostamatinib) requires prior authorization from Cigna for adults with chronic ITP. You'll need a hematologist's prescription, platelet count <30,000/μL (or <50,000/μL with bleeding), and it's dispensed through Accredo Specialty Pharmacy as a Tier 4 medication. If denied, you have 180 days to file an internal appeal, then 4 months for external review through NY Department of Financial Services. Start today: Have your doctor call Cigna for a peer-to-peer review (1-800-88-CIGNA) while gathering lab results and prior treatment records.

Table of Contents

  1. Is Tavalisse Covered by Cigna?
  2. Prior Authorization Requirements
  3. Submission Process and Timeline
  4. Coverage Criteria and Common Denials
  5. Cost and Specialty Pharmacy
  6. Appeals Process in New York
  7. Renewal and Reauthorization
  8. Troubleshooting and Support
  9. Frequently Asked Questions

Is Tavalisse Covered by Cigna?

Yes, Tavalisse (fostamatinib disodium hexahydrate) is covered by most Cigna plans in New York, but with significant restrictions. The medication is typically placed on Tier 4 of Cigna's formulary—the highest cost-sharing tier for specialty medications—and requires prior authorization before coverage begins.

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all plans Cigna PA Policy CNF-625
Formulary Tier Tier 4 (highest copay/coinsurance) Cigna National Formulary
Specialty Pharmacy Accredo required Cigna Specialty Pharmacy
Age Requirement 18 years or older Cigna PA Policy
Prescriber Hematologist or consultation required Cigna PA Policy

Prior Authorization Requirements

Cigna's prior authorization for Tavalisse follows strict medical necessity criteria based on FDA labeling and clinical guidelines for chronic immune thrombocytopenia (ITP).

Initial Approval Criteria

Your doctor must document all of the following:

  • Patient age: 18 years or older
  • Diagnosis: Chronic immune thrombocytopenia (ITP) with appropriate ICD-10 code
  • Prescriber: Hematologist or documented consultation with hematology
  • Platelet count: Either:
    • Less than 30,000/μL (30 × 10⁹/L), OR
    • Less than 50,000/μL (50 × 10⁹/L) with documented bleeding risk despite rescue therapy
  • Clinical documentation: Recent lab results, bleeding episodes, rescue medication history
Note: Initial approval is typically granted for 3 months to evaluate treatment response.

Submission Process and Timeline

Step-by-Step: Fastest Path to Approval

  1. Hematologist consultation (if not already established)
    • Schedule with hematology/oncology specialist
    • Ensure consultation notes document ITP diagnosis and treatment history
  2. Gather required documentation
    • Recent platelet counts (within 30 days)
    • Complete blood count (CBC) results
    • Documentation of bleeding episodes or risk factors
    • Prior treatment history and outcomes
  3. Provider submits PA request
    • Via CignaforHCP.com provider portal
    • Or fax to Cigna PA department (number on provider portal)
    • Include all clinical documentation and lab results
  4. Standard processing time: 5-7 business days
    • Expedited review: 24-72 hours if urgent medical need documented
  5. If approved: Prescription sent to Accredo Specialty Pharmacy
    • Accredo contacts patient directly for delivery coordination
    • First fill typically ships within 24-48 hours

Required Documentation Checklist

  • Completed PA form with provider signature
  • Recent platelet count lab results
  • Hematologist consultation notes or prescriber credentials
  • Documentation of bleeding risk or episodes
  • Prior treatment history (if applicable)
  • Patient demographics and insurance information

Coverage Criteria and Common Denials

Understanding why Tavalisse gets denied helps you prepare a stronger initial request or appeal.

Common Denial Reasons and Solutions

Denial Reason How to Address Documentation Needed
No hematologist involvement Obtain hematology consultation Consultation notes or prescriber credentials
Insufficient platelet documentation Submit recent lab results CBC with platelet count <30,000/μL or <50,000/μL with bleeding
Age under 18 Confirm patient age Birth date verification
Lack of bleeding documentation Document clinical symptoms Notes on bleeding episodes, bruising, or risk factors
Missing clinical rationale Provide detailed justification Treatment goals, expected outcomes, monitoring plan

Medical Necessity Requirements

Cigna defines medical necessity for Tavalisse based on:

  • Chronic ITP diagnosis confirmed by hematologist
  • Platelet count meeting threshold criteria
  • Appropriate patient age (≥18 years)
  • Clinical documentation of bleeding risk or episodes
  • Prescriber expertise in hematology

Cost and Specialty Pharmacy

Expected Costs

As a Tier 4 specialty medication, Tavalisse typically involves significant out-of-pocket costs:

  • Tier 4 copay: Often $100-300+ per month
  • Coinsurance: May be 25-50% of drug cost after deductible
  • Annual drug cost: Approximately $168,000-192,000 based on wholesale pricing
Financial assistance: Rigel Pharmaceuticals offers a copay assistance program. Visit RigelRx.com or call 1-833-TAVALISSE for eligibility information.

Accredo Specialty Pharmacy Process

  1. Automatic transfer: Once approved, prescription goes to Accredo
  2. Patient contact: Accredo pharmacist calls to verify information
  3. Delivery coordination: Medication ships overnight with temperature control
  4. Ongoing support: 24/7 pharmacist availability and nursing support

Contact Accredo directly: 1-800-803-2523

Appeals Process in New York

If Cigna denies your Tavalisse prior authorization, New York provides robust appeal rights with multiple levels of review.

Internal Appeal (Required First Step)

Timeline: File within 180 days of denial notice

  1. Gather appeal materials:
    • Original denial letter
    • Updated clinical documentation
    • Peer-reviewed literature supporting use
    • Provider letter addressing denial reasons
  2. Submit to Cigna:
    • Address: Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
    • Fax: Use number provided in denial letter
    • Online: Cigna provider portal
  3. Response timeline: 30 days for pre-service appeals
Tip: Request a peer-to-peer review with Cigna's medical director. Call 1-800-88-CIGNA to schedule. Many denials are overturned when the prescribing hematologist speaks directly with Cigna's reviewer.

New York External Appeal

If Cigna upholds the denial, you can request an independent external review through the New York State Department of Financial Services (DFS).

Key Details:

  • Filing deadline: 4 months after final internal denial
  • Cost: $25 (waived for financial hardship or Medicaid)
  • Timeline: 30 days standard, 72 hours expedited
  • Success rate: Approximately 50% of appeals overturn denials

How to file:

  1. Visit DFS External Appeal Portal
  2. Submit denial letters, clinical records, and provider support letter
  3. Include peer-reviewed studies on Tavalisse efficacy in ITP

Free Help Available

Community Health Advocates: 888-614-5400

  • Free assistance with appeals and insurance denials
  • Available to all New York residents
  • Can help prepare documentation and file appeals

Renewal and Reauthorization

Continuation Criteria

After initial 3-month approval, reauthorization requires evidence of clinical benefit:

  • Platelet response: Increase in platelet count or stabilization
  • Bleeding reduction: Fewer bleeding episodes or reduced severity
  • Ongoing medical necessity: Continued risk without treatment
  • Tolerability: No prohibitive side effects

Reauthorization Timeline

  • Submit renewal: 30 days before current authorization expires
  • Approval duration: Up to 12 months for documented responders
  • Required labs: Updated platelet counts and safety monitoring
Important: Cigna may discontinue coverage if no platelet response after 12 weeks of therapy, per FDA labeling guidance.

Troubleshooting and Support

Common Issues and Solutions

Portal access problems:

  • Call Cigna provider services: 1-800-88-CIGNA
  • Verify provider enrollment and credentials

Missing documentation:

  • Contact medical records: Request complete hematology consultation notes
  • Lab results: Ensure recent platelet counts are clearly documented

Prescription delays:

  • Check with Accredo: 1-800-803-2523
  • Verify PA approval status through Cigna portal

When to Escalate

Contact New York regulators if you experience:

  • Missed appeal deadlines by Cigna
  • Lack of response to expedited requests
  • Denial of clearly covered services

New York Department of Financial Services: 1-800-342-3736

Frequently Asked Questions

How long does Cigna prior authorization take for Tavalisse? Standard processing is 5-7 business days. Expedited reviews for urgent cases take 24-72 hours with proper medical documentation.

What if Tavalisse isn't on my specific Cigna formulary? You can request a formulary exception through your doctor. Provide clinical rationale for why formulary alternatives aren't appropriate.

Can I get Tavalisse at a regular pharmacy? No, Cigna requires specialty pharmacy dispensing through Accredo due to the medication's complexity and monitoring requirements.

Does step therapy apply to Tavalisse? Cigna doesn't require specific step therapy, but you must meet platelet count thresholds and have hematologist involvement.

What if I move from another state to New York? Your prior treatment history from any state counts toward meeting Cigna's criteria. Ensure your new hematologist documents this history.

How do I check my appeal status? Log into your Cigna member portal or call customer service. For external appeals in New York, check the DFS portal where you filed.

This guide provides educational information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan and clinical circumstances. For personalized assistance with complex insurance denials and appeals, Counterforce Health helps patients and providers turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical documentation to draft point-by-point rebuttals aligned with payer requirements.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and should not replace professional medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage decisions.

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