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

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

Quick Answer: Getting Tavalisse Covered by Cigna in Texas

Cigna covers Tavalisse (fostamatinib) for adults with chronic ITP after step therapy requirements are met. Your fastest path to approval: 1) Confirm you've tried required first-line treatments (steroids, IVIG, or TPO receptor agonists), 2) Have your hematologist submit a prior authorization through Cigna's provider portal with complete clinical documentation, and 3) If denied, file an internal appeal within 180 days. Standard PA decisions take 72 hours; appeals follow Texas's mandated external review process through independent reviewers.

Table of Contents

Start Here: Verify Your Plan and Find the Right Forms

Before starting your Tavalisse approval process, confirm your specific Cigna plan details. Coverage criteria can vary between commercial plans, Medicare Advantage, and employer-sponsored benefits.

What You'll Need to Gather:

  • Your Cigna insurance card (member ID and group number)
  • Complete diagnosis documentation for chronic ITP
  • Records of prior treatments tried and failed
  • Current platelet counts and lab results
  • Hematologist consultation notes
Tip: Texas law prohibits insurers from requiring multiple prior authorizations for the same drug and indication within the same calendar year, streamlining renewal requests.

Coverage Criteria at a Glance

Requirement Details Source
Age ≥18 years old Cigna Policy
Diagnosis Chronic ITP (≥12 months duration) Cigna Policy
Platelet Count <30 × 10⁹/L OR <50 × 10⁹/L with bleeding risk Cigna Policy
Step Therapy Failed ≥1 prior therapy or had splenectomy Cigna Policy
Prescriber Hematologist or in consultation with one Cigna Policy
Monitoring CBC, liver function, blood pressure Cigna Policy

Prior Authorization Requirements

Cigna requires prior authorization for Tavalisse, with specific clinical criteria that must be documented in your request.

Step Therapy Requirements

You must have tried and failed (or have contraindications to) at least one of these treatments:

  • Corticosteroids
  • Intravenous immunoglobulin (IVIG)
  • Anti-D immunoglobulin
  • Thrombopoietin receptor agonists (eltrombopag/Promacta, romiplostim/Nplate, avatrombopag/Doptelet)
  • Rituximab
  • OR underwent splenectomy

Clinical Documentation Checklist

Your hematologist's prior authorization request must include:

Diagnosis Documentation:

  • ICD-10 code for chronic ITP
  • Duration of thrombocytopenia (≥12 months)
  • Current platelet count with date

Treatment History:

  • Specific medications tried with dates
  • Reasons for discontinuation (lack of efficacy, intolerance, contraindications)
  • Duration of each treatment trial

Current Clinical Status:

  • Recent CBC with differential
  • Liver function tests (ALT, AST, bilirubin)
  • Blood pressure readings
  • Bleeding history or risk assessment

Monitoring Plan:

  • Schedule for ongoing lab monitoring
  • Blood pressure monitoring protocol
Note: Tavalisse cannot be used concurrently with other thrombopoietic agents like Doptelet, Promacta, or Nplate.

Submission Process: Forms and Portals

Provider Portal Submission

Providers submit prior authorization requests through the Cigna for Health Care Professionals portal. As of September 2025, login screens have been updated but existing credentials remain valid.

Required Documentation Upload:

  • Prior authorization form (completed)
  • Medical records supporting diagnosis
  • Lab results (CBC, liver function tests)
  • Treatment history documentation
  • Hematology consultation notes

File Requirements:

  • Formats: PDF, TIFF, or JPG
  • Size limit: Typically 5-10 MB per file
  • Documents must be legible and contain patient identifiers

Timeline Expectations

Request Type Cigna Decision Timeline
Standard PA 72 hours from complete submission
Expedited/Urgent 24 hours (requires physician certification)

Common Denial Reasons and How to Fix Them

Denial Reason Solution Required Documentation
Insufficient step therapy Document all prior treatments tried Pharmacy records, physician notes showing dates, drugs, outcomes
Platelet count not documented Submit recent lab results CBC with differential within 30 days
Not prescribed by hematologist Get hematology consultation Referral letter or consultation note
Missing monitoring plan Include surveillance protocol Lab monitoring schedule, BP check plan
Concurrent TPO agent use Discontinue other agents first Documentation of medication discontinuation

Appeals Process in Texas

If your initial prior authorization is denied, Texas law provides strong appeal rights with specific timelines.

Internal Appeal Process

Timeline: You have 180 days from the denial date to file an internal appeal.

Cigna's Response Timeline:

  • Standard appeals: 30 days for pre-service requests
  • Expedited appeals: 72 hours for urgent cases

How to File:

  1. Use the appeal form included with your denial letter
  2. Submit via Cigna's provider portal or fax (number on denial letter)
  3. Include additional clinical documentation addressing denial reasons

External Review (Independent Review)

If Cigna upholds the denial, you can request external review by an Independent Review Organization (IRO).

Timeline:

  • Request within 4 months of final internal denial
  • IRO decision within 20 days (5 days for urgent cases)

Texas Department of Insurance Support:

  • Consumer Helpline: 1-800-252-3439
  • IRO Information Line: 1-866-554-4926

The IRO's decision is binding—if they overturn the denial, Cigna must provide coverage.

Specialty Pharmacy Setup

Once approved, Tavalisse is typically dispensed through Cigna's specialty pharmacy network, primarily Accredo.

Accredo Specialty Pharmacy:

  • Phone: 877-826-7657 (24/7 support)
  • Services: Home delivery, clinical support, refill coordination
  • Nurse case management for side effect monitoring

Transfer Process:

  1. Your prescriber sends the prescription to Accredo
  2. Accredo contacts you to verify insurance and delivery preferences
  3. Clinical pharmacist reviews therapy and provides education
  4. Medication ships with temperature-controlled packaging
From our advocates: We've seen patients experience smoother transitions when they proactively call Accredo after PA approval to introduce themselves and confirm their contact preferences. This helps avoid delays in the initial shipment and ensures you're connected with a dedicated care team from day one.

Support Contacts and Resources

Cigna Member Services

  • Phone number on your insurance card
  • myCigna portal for prescription tracking
  • Case management requests through member services

Provider Support

  • Cigna Provider Services: Number on patient's insurance card
  • Accredo Provider Line: 877-826-7657
  • Prior authorization status checks via provider portal

Texas Consumer Assistance

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • Disability Rights Texas: For complex cases requiring advocacy support

Cost Assistance Options

Even with insurance coverage, Tavalisse can involve significant out-of-pocket costs.

Manufacturer Support:

  • Rigel Pharmaceuticals patient assistance programs
  • Copay assistance cards (verify eligibility with commercial insurance)

Foundation Resources:

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • Leukemia & Lymphoma Society copay assistance

State Resources:

  • Texas has not expanded Medicaid, limiting low-income assistance options
  • Community health centers may provide care coordination support

Counterforce Health helps patients navigate these complex insurance processes by turning denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with payer requirements, incorporating the right clinical evidence and procedural details that specialty drug approvals demand.

Frequently Asked Questions

How long does Cigna prior authorization take for Tavalisse in Texas? Standard requests receive decisions within 72 hours of complete submission. Expedited requests (when physician certifies urgency) are decided within 24 hours.

What if Tavalisse is not on my Cigna formulary? You can request a formulary exception. Cigna must respond to exception requests within 72 hours for standard cases, 24 hours for urgent requests.

Can I get an expedited appeal if denied? Yes, if your physician certifies that delays could seriously jeopardize your health. Expedited appeals receive decisions within 72 hours.

Does step therapy apply if I tried treatments in another state? Yes, prior treatment history from other states counts toward step therapy requirements. Ensure your provider includes complete documentation from previous physicians.

What happens if I miss an appeal deadline? Texas allows internal appeals within 180 days of denial. If you miss this deadline, you may lose appeal rights, though extraordinary circumstances might allow extensions.

Who pays for the external review process? Cigna pays all costs for the Independent Review Organization evaluation. There are no fees to you for external review.

Can I continue current ITP treatments while appealing? Discuss with your hematologist. Some patients may need bridging therapy during the appeal process, but Tavalisse cannot be used with other TPO receptor agonists.

What if I need Tavalisse urgently? Request expedited prior authorization and, if denied, expedited appeals. Your physician must certify that delays would jeopardize your health.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan, and policies change frequently. Always consult your healthcare provider for medical decisions and verify current coverage details with your insurer. For assistance with insurance appeals in Texas, contact the Texas Department of Insurance at 1-800-252-3439.

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