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

How to Get Tavalisse (Fostamatinib) Covered by Cigna in Washington: Complete Prior Authorization & Appeal Guide

Quick Answer: Getting Tavalisse Covered by Cigna in Washington

Fastest path to approval: Your hematologist must submit a prior authorization showing you've tried and failed corticosteroids and at least one other ITP therapy (like IVIG or a TPO receptor agonist), with documented platelet counts <30,000/µL. If denied, Washington gives you strong appeal rights including external review through an Independent Review Organization. Start today: Gather your complete treatment history and schedule an appointment with your hematologist to review Cigna's specific step therapy requirements.

Table of Contents

  1. Set Your Goal: What Cigna Requires for Tavalisse
  2. Preparing for Your Hematologist Visit
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Your Doctor in Peer-to-Peer Reviews
  6. After Your Visit: Next Steps
  7. Appeals Process in Washington
  8. Cost Support Options
  9. When to Contact Washington Regulators
  10. Frequently Asked Questions

Set Your Goal: What Cigna Requires for Tavalisse

Tavalisse (fostamatinib disodium hexahydrate) is an oral medication for chronic immune thrombocytopenia (ITP) that costs approximately $14,000-$16,000 per month. Cigna requires prior authorization and has specific step therapy requirements you and your doctor must meet.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Diagnosis Chronic ITP lasting ≥3 months ICD-10 code, lab history
Step Therapy Failed corticosteroids + other therapy Treatment records, dates, outcomes
Prescriber Hematologist or consultation Specialist credentials, referral
Platelet Count <30,000/µL (or <50,000 with bleeding) Recent lab results
Prior Failures Documented inadequate response Chart notes, side effects

Your partnership goal: Work with your hematologist to document that Tavalisse is medically necessary because standard treatments haven't worked for your specific case.

Preparing for Your Hematologist Visit

Before meeting with your doctor, compile a comprehensive timeline of your ITP journey. This preparation makes the difference between a quick approval and a lengthy appeals process.

What to Document

Symptom Timeline:

  • When did your platelet count first drop?
  • What symptoms led to diagnosis (bruising, bleeding, fatigue)?
  • How has ITP affected your daily activities?

Treatment History:

  • List every ITP medication you've tried
  • Include dates, dosages, and duration of each treatment
  • Note specific reasons each treatment failed or caused problems

Current Status:

  • Recent platelet counts (bring lab printouts)
  • Any bleeding episodes or hospitalizations
  • Current medications and supplements
Tip: Create a simple timeline document before your visit. Many patients find this helps their doctor write a stronger prior authorization request.

Building Your Evidence Kit

Your hematologist needs specific documentation to justify Tavalisse to Cigna. Help them gather the strongest possible case.

Essential Documents

Laboratory Evidence:

  • Platelet counts from diagnosis through present
  • Complete blood counts showing persistent thrombocytopenia
  • Any bone marrow biopsy results (if performed)

Treatment Records:

  • Discharge summaries from ITP-related hospitalizations
  • Notes from previous hematologists or specialists
  • Pharmacy records showing filled prescriptions for prior ITP treatments

Guideline Support: The American Society of Hematology 2019 ITP guidelines recommend fostamatinib as a second-line option for chronic ITP patients who are corticosteroid-dependent or unresponsive.

Clinical Rationale Components

Your doctor's prior authorization should address:

  • Diagnosis confirmation: Chronic ITP with inadequate response to first-line therapy
  • Failed treatments: Specific medications tried, why they didn't work
  • Bleeding risk: Current symptoms and functional limitations
  • Treatment goals: Expected platelet response and quality of life improvement

Medical Necessity Letter Structure

Counterforce Health specializes in turning insurance denials into successful appeals by crafting evidence-backed letters that address each insurer's specific requirements. Here's the structure your hematologist should follow for Cigna:

Key Letter Components

Patient Information Block:

  • Full name, date of birth, Cigna member ID
  • Diagnosis with ICD-10 code (D69.3 for chronic ITP)
  • Prescriber information including NPI number

Clinical Justification:

  1. Diagnosis confirmation with supporting lab values
  2. Treatment history showing step therapy compliance
  3. Medical necessity explaining why Tavalisse is appropriate
  4. Contraindications to formulary alternatives (if applicable)
  5. Expected outcomes and monitoring plan

Supporting Evidence:

  • Reference to ASH guidelines supporting fostamatinib use
  • Attached lab results and treatment records
  • Documentation of bleeding risk or quality of life impact
From Our Advocates: We've seen the strongest approvals when doctors include specific platelet count trends over time and clearly explain why each prior therapy was inadequate. A simple statement like "patient failed prednisone due to intolerance" is less compelling than "patient developed severe mood changes and weight gain on prednisone 60mg daily, requiring discontinuation after 6 weeks with platelets remaining <20,000/µL."

Supporting Your Doctor in Peer-to-Peer Reviews

If Cigna's medical director requests a peer-to-peer review, your hematologist will speak directly with Cigna's physician reviewer. You can help prepare them for this conversation.

Preparation Checklist

Key Points to Emphasize:

  • Your specific response (or lack thereof) to each prior therapy
  • Current bleeding risk and functional limitations
  • Why formulary alternatives aren't appropriate for your case
  • Alignment with published treatment guidelines

Availability Windows:

  • Offer flexible scheduling to accommodate the peer-to-peer call
  • Ensure your doctor has all records easily accessible
  • Consider being available for questions about your experience

Concise Case Summary: Help your doctor prepare a 2-minute summary covering:

  1. Diagnosis and duration of chronic ITP
  2. Prior treatments attempted and outcomes
  3. Current clinical status and bleeding risk
  4. Rationale for Tavalisse specifically

After Your Visit: Next Steps

Once your hematologist submits the prior authorization, track the process carefully.

Timeline Expectations

Standard Review: Cigna typically responds within 72 hours for non-urgent requests Expedited Review: 24 hours for urgent cases where delay could harm your health

What to Save

  • Copy of the prior authorization request
  • Cigna's determination letter (approval or denial)
  • All correspondence with your doctor's office
  • Documentation of any phone calls with Cigna

Portal Communication

Use your healthcare provider's patient portal to:

  • Request copies of submitted documentation
  • Ask for updates on the prior authorization status
  • Share any new symptoms or lab results

Appeals Process in Washington

Washington state provides strong consumer protections if Cigna denies coverage for Tavalisse. The state's external review process gives you multiple chances to overturn denials.

Step-by-Step Appeals Process

1. Internal Appeal (Required First Step)

  • Timeline: File within 180 days of denial
  • Process: Submit additional evidence through Cigna
  • Duration: Standard decisions within 30 days, expedited within 72 hours

2. External Review (Independent Review Organization)

  • Eligibility: After completing internal appeal or if Cigna misses deadlines
  • Timeline: Up to 4 months after final internal denial to request
  • Process: Independent medical experts review your case
  • Outcome: Decision is binding on Cigna

Washington External Review Timeline

Plan Type Standard Decision Expedited Decision
Fully-insured 15 days 72 hours
Self-insured 45 days 72 hours

Contact for Help: Washington Office of the Insurance Commissioner Consumer Advocacy line: 1-800-562-6900

Cost Support Options

Even with insurance coverage, Tavalisse may have significant out-of-pocket costs. Several programs can help reduce your expenses.

Manufacturer Support

Rigel Pharmaceuticals Patient Assistance:

  • Copay assistance for commercially insured patients
  • Patient assistance program for uninsured/underinsured
  • Contact: (verify current program details with Rigel)

Additional Resources

State Programs:

  • Washington Apple Health (Medicaid) may cover Tavalisse with prior authorization
  • State pharmaceutical assistance programs for seniors

Foundation Grants:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

When to Contact Washington Regulators

If you feel Cigna isn't following proper procedures or if appeals aren't progressing appropriately, Washington's Insurance Commissioner can help.

When to File a Complaint

  • Cigna misses appeal deadlines
  • Requests for information seem unreasonable
  • You suspect discrimination based on your condition
  • External review process isn't working properly

How to File

Washington Office of the Insurance Commissioner:

  • Online complaint form at insurance.wa.gov
  • Phone: 1-800-562-6900
  • Include all documentation and correspondence

Frequently Asked Questions

How long does Cigna prior authorization take in Washington? Standard requests receive decisions within 72 hours. Expedited requests for urgent cases are decided within 24 hours.

What if Tavalisse is non-formulary on my Cigna plan? You can request a formulary exception with medical justification from your hematologist.

Can I request an expedited appeal? Yes, if delay in treatment could seriously jeopardize your health. Washington requires expedited decisions within 72 hours.

Does step therapy apply if I tried treatments outside Washington? Yes, documented treatment failures from other states count toward Cigna's step therapy requirements.

What happens if the external review upholds Cigna's denial? The external review decision is final and binding. Your next option would be legal action, though you should consult with an attorney about the viability of such action.

How much does the external review process cost? Washington patients typically pay no fee for external review. The insurance company pays the Independent Review Organization.

Can my family member help with appeals? Yes, but you'll need to designate them as your authorized representative in writing to Cigna.

What if I have a self-funded employer plan? Self-funded plans may not be subject to all Washington state laws, but many voluntarily use external review. Contact the U.S. Department of Labor for ERISA plan appeals guidance.

About This Guide: Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance approvals by turning denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned with each plan's specific requirements, pulling the right clinical evidence and meeting all procedural requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current insurance policies and state regulations, as these can change. For personalized assistance with insurance appeals, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

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