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

How to Get Tavalisse (Fostamatinib) Covered by Cigna in North Carolina: Prior Authorization Guide with Appeals Process

Quick Answer: Getting Tavalisse Covered by Cigna in North Carolina

Tavalisse (fostamatinib) requires prior authorization from Cigna for chronic ITP treatment. You'll need documented failure of at least one prior therapy (steroids, IVIG, or TPO receptor agonists), hematologist involvement, and baseline labs. The fastest path: have your hematologist submit a complete PA request through Cigna's provider portal with all required documentation. If denied, North Carolina's Smart NC external review program offers binding appeals with 45-day standard timelines. First step today: confirm your plan covers specialty drugs through Express Scripts/Accredo and gather your prior therapy documentation.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in North Carolina
  7. If You Need More Information
  8. If Your Request is Denied
  9. Renewal and Reauthorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This guide helps North Carolina patients and their healthcare providers navigate Cigna's prior authorization process for Tavalisse (fostamatinib disodium hexahydrate), an oral medication for adults with chronic immune thrombocytopenia (ITP) who haven't responded adequately to previous treatments.

Tavalisse typically costs around $14,000-$16,000 per 60-tablet bottle and requires careful documentation of medical necessity. With proper preparation, most eligible patients can secure coverage, though the process may take several weeks.

Who this helps:

  • Patients with chronic ITP prescribed Tavalisse by their hematologist
  • Healthcare providers submitting PA requests to Cigna
  • Caregivers navigating insurance appeals in North Carolina

Before You Start: Verify Your Coverage

Check Your Plan Type

Cigna typically covers Tavalisse under the pharmacy benefit through their specialty pharmacy network, primarily Express Scripts and Accredo. Before starting the PA process:

  1. Confirm specialty drug coverage: Call Cigna member services to verify your plan includes specialty pharmacy benefits
  2. Check formulary status: Tavalisse may be on a higher formulary tier requiring higher copays
  3. Verify network status: Ensure your prescribing hematologist is in-network with Cigna
Note: Self-funded employer plans may have different rules than standard Cigna policies. Verify your specific plan's requirements.

Pharmacy vs. Medical Benefit

Tavalisse is almost always processed under the pharmacy benefit when dispensed by specialty pharmacies like Accredo. The medical benefit pathway would only apply if administered in a clinical setting, which is rare for this oral medication.

Gather Required Documentation

Core Requirements for Cigna PA

Based on Cigna's clinical criteria, you'll need:

Requirement Details Documentation Needed
Diagnosis Chronic ITP, at risk for bleeding ICD-10 code D69.3, hematologist notes
Age Adult (≥18 years) Date of birth verification
Prior Therapy Failed/intolerant to ≥1 prior treatment Treatment records, response documentation
Specialist Prescribed by hematologist Provider credentials, consultation notes
Lab Values Baseline CBC, liver function tests Recent lab results (<30 days preferred)
Monitoring Plan Ongoing CBC and LFT monitoring Provider attestation of monitoring schedule

Prior Therapy Documentation

Cigna requires evidence of inadequate response or intolerance to at least one of:

  • Corticosteroids (prednisone, methylprednisolone)
  • Intravenous immunoglobulin (IVIG)
  • Thrombopoietin receptor agonists (eltrombopag, romiplostim)
  • Other therapies like rituximab or splenectomy

Document specific details: dates of treatment, dosages, duration, platelet count response, and reasons for discontinuation.

Clinical Documentation Checklist

  • Diagnosis of chronic ITP (>12 months duration)
  • Current platelet count (typically <50,000/μL)
  • Prior therapy history with outcomes
  • Bleeding risk assessment
  • Contraindications to alternative treatments
  • Baseline CBC and comprehensive metabolic panel
  • Blood pressure readings (Tavalisse can cause hypertension)

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Access Cigna's Provider Portal

  • Healthcare providers should use cignaforhcp.com (verify current link with Cigna)
  • Download the current Tavalisse PA form or initiate electronic submission

2. Complete Required Sections

  • Patient demographics and insurance information
  • Diagnosis with ICD-10 code D69.3
  • Prescriber information (must be hematologist or in consultation with one)
  • Clinical justification with prior therapy details

3. Attach Supporting Documents

  • Recent lab results (CBC, LFTs, creatinine)
  • Prior therapy documentation
  • Hematologist consultation notes
  • Any relevant imaging or additional testing

4. Submit and Track

  • Submit via provider portal or fax (confirm current fax number)
  • Document submission date and reference number
  • Set calendar reminder for follow-up
Tip: Incomplete submissions are the most common cause of delays. Double-check all required fields before submitting.

Medical Necessity Letter Template

If submitting a separate medical necessity letter, include:

  1. Patient summary: Age, diagnosis, disease duration
  2. Prior treatments: Specific therapies tried, dates, outcomes, reasons for discontinuation
  3. Current clinical status: Platelet counts, bleeding symptoms, functional impact
  4. Treatment rationale: Why Tavalisse is appropriate, expected benefits
  5. Monitoring plan: Lab schedule, safety assessments
  6. Supporting literature: FDA labeling, clinical guidelines if relevant

Follow-Up and Tracking

  • Day 3-5: Confirm receipt of submission
  • Day 10-14: Check processing status
  • Day 18-20: Follow up if no decision received

What to Ask When Calling

"I'm calling about a prior authorization request for Tavalisse submitted on [date] for patient [name], member ID [number]. Can you provide the current status and any additional information needed?"

Key information to document:

  • Reference number
  • Current status (pending, under review, approved, denied)
  • Expected decision date
  • Any additional documentation requests

Typical Timelines in North Carolina

Standard Processing Times

Cigna's standard timelines:

  • Non-urgent requests: Up to 72 hours after receipt of complete documentation
  • Urgent requests: Within 24 hours for cases where delay could jeopardize health

North Carolina-Specific Considerations

North Carolina insurance regulations require insurers to process PA requests within reasonable timeframes. If Cigna doesn't meet their stated timelines, this can strengthen an appeal.

Factors that speed approval:

  • Complete documentation on first submission
  • Clear evidence of prior therapy failures
  • Hematologist as prescriber
  • Recent lab values supporting medical necessity

Common delays:

  • Missing prior therapy documentation
  • Incomplete lab results
  • Non-specialist prescriber requiring consultation

If You Need More Information

Handling Additional Documentation Requests

If Cigna requests more information:

  1. Respond promptly: Submit within the timeframe specified (usually 14 days)
  2. Be specific: Address exactly what was requested
  3. Include context: Explain why the additional information supports medical necessity
  4. Follow up: Confirm receipt and ask for updated timeline

Common Information Requests

  • More detailed prior therapy records
  • Recent platelet counts or bleeding episodes
  • Specialist consultation if prescribed by primary care
  • Dosing justification or monitoring plan details

If Your Request is Denied

Understanding Denial Reasons

Common Cigna denial codes for Tavalisse:

Denial Reason How to Address
Insufficient prior therapy Provide detailed records of failed treatments
Not prescribed by specialist Obtain hematology consultation
Missing lab values Submit recent CBC and liver function tests
Not medically necessary Strengthen clinical justification with guidelines

Cigna Internal Appeals Process

First-Level Internal Appeal:

  • Submit within 180 days of denial notice
  • Include additional clinical documentation
  • Request peer-to-peer review if appropriate
  • Timeline: Up to 30 days for standard, 72 hours for urgent

Second-Level Internal Appeal:

  • Available if first-level appeal is denied
  • Must be submitted within specified timeframe
  • Final internal review before external options

At Counterforce Health, we help patients and providers turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific requirements.

North Carolina External Review: Smart NC

If Cigna denies your internal appeals, North Carolina's Smart NC program offers binding external review:

Process:

  1. File within 120 days of final internal denial
  2. Submit external review form to NC Department of Insurance
  3. Independent medical reviewers evaluate your case
  4. Decision is binding on Cigna

Timeline:

  • Standard review: 45 days maximum
  • Expedited review: 4 business days for urgent cases

Contact Smart NC:

  • Phone: 1-855-408-1212
  • Provides free guidance and form assistance
  • Can help gather supporting documentation
From our advocates: We've seen many Tavalisse denials overturned when patients provide comprehensive prior therapy documentation and work with their hematologist to submit detailed clinical justification. The key is often showing specific platelet count trends and bleeding risk factors that weren't adequately addressed by previous treatments.

Renewal and Reauthorization

When to Start Renewal Process

Begin reauthorization 30-45 days before your current approval expires. Cigna typically approves Tavalisse for 12-month periods initially.

Renewal Documentation

  • Current platelet counts showing treatment response
  • Continued bleeding risk assessment
  • Adherence documentation
  • Any adverse effects and management
  • Updated liver function tests and blood pressure readings

Evidence of Treatment Benefit

Document clinical improvements such as:

  • Increased platelet counts
  • Reduced bleeding episodes
  • Improved quality of life measures
  • Ability to reduce or avoid rescue therapies

Quick Reference Checklist

Before Submitting PA Request

  • Verify Cigna specialty pharmacy coverage
  • Confirm hematologist is prescriber
  • Gather complete prior therapy records
  • Obtain recent lab results (CBC, LFTs)
  • Document current bleeding risk

Required Documentation

  • ICD-10 code D69.3 (immune thrombocytopenic purpura)
  • Evidence of ≥1 failed prior therapy
  • Baseline platelet count documentation
  • Hematologist consultation notes
  • Monitoring plan attestation

If Denied

  • Review denial letter carefully
  • Gather additional supporting documentation
  • Submit internal appeal within 180 days
  • Consider peer-to-peer review request
  • Prepare for external review if needed

FAQ

How long does Cigna prior authorization take for Tavalisse in North Carolina? Standard requests take up to 72 hours once complete documentation is received. Urgent requests are processed within 24 hours.

What if Tavalisse is non-formulary on my Cigna plan? You can request a formulary exception by demonstrating medical necessity and providing clinical justification for why formulary alternatives aren't appropriate.

Can I request an expedited appeal in North Carolina? Yes, both Cigna and North Carolina's Smart NC program offer expedited reviews for urgent medical situations where delays could jeopardize health.

Does step therapy apply if I failed treatments outside North Carolina? Yes, prior therapy documentation from any location is acceptable as long as it's properly documented and meets Cigna's clinical criteria.

What counts as "adequate trial" of prior therapy? Generally, an adequate trial means therapeutic dosing for sufficient duration (usually several weeks to months) with documented platelet count monitoring and clinical response assessment.

How much will Tavalisse cost with Cigna coverage? Costs vary by plan, but specialty tier copays typically range from $50-$500+ per month. Manufacturer copay assistance may be available for eligible patients.

What if my hematologist isn't in Cigna's network? You may need to obtain consultation from an in-network hematologist or request a network exception if no appropriate specialists are available in your area.

Can Smart NC help with the appeals process? Yes, Smart NC provides free guidance, helps with form completion, and can assist in gathering supporting documentation for external reviews.

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. For specific questions about your coverage, contact Cigna member services directly.

Need help with complex appeals? Counterforce Health specializes in turning insurance denials into successful approvals by creating targeted, evidence-backed appeals that address each payer's specific requirements.

Sources & Further Reading

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