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

How to Get Tavalisse (Fostamatinib) Covered by Humana in Florida: Complete Prior Authorization and Appeal Guide

Answer Box: Getting Tavalisse Covered by Humana in Florida

Humana requires prior authorization for Tavalisse (fostamatinib) in Florida. You need documented failure of corticosteroids and at least one TPO receptor agonist (like eltrombopag or romiplostim), plus current platelet counts <30,000/μL and hematologist involvement. Submit requests through Availity Essentials or call 800-523-0023. Standard decisions come within 7 days; appeals have a 65-day window. If denied initially, peer-to-peer reviews and external appeals through Florida's Department of Financial Services often succeed—about 4 in 5 Medicare appeals are eventually approved.

First step today: Contact your hematologist to gather documentation of previous treatment failures and current lab values.

Table of Contents

Understanding Tavalisse Coverage Requirements

Tavalisse (fostamatinib disodium hexahydrate) is an oral SYK inhibitor approved for adults with chronic immune thrombocytopenia (ITP) who haven't responded adequately to previous treatments. At roughly $14,000–$16,000 per 60-tablet bottle, Humana requires prior authorization for all Medicare Advantage and Dual Special Needs Plan members in Florida.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required Must get approval before filling prescription Humana PA Lists
Step Therapy Must try steroids + TPO-RA first Clinical guidelines, payer policy
Platelet Count Documentation Current counts <30,000/μL typically required Recent lab reports
Hematologist Involvement Specialist must prescribe and justify Provider attestation letter
ICD-10 Code D69.3 (Primary ITP) with exclusion of secondary causes Medical records

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

  • Recent platelet counts (within 1-2 weeks, showing <30,000/μL)
  • Documentation of failed prior therapies: Corticosteroids (prednisone/dexamethasone) and at least one TPO receptor agonist
  • Exclusion of secondary causes: Normal peripheral smear, negative infection screening
  • Current symptoms/bleeding risk assessment

2. Have Your Hematologist Submit the Request (Clinic)

Preferred method: Availity Essentials portal for real-time processing Alternative: Phone 800-523-0023 or fax 888-447-3430 Timeline: Decision within 7 days for standard requests

3. Include Complete Clinical Justification (Clinic)

Your hematologist's letter must document:

  • Confirmed ITP diagnosis with appropriate exclusions
  • Specific prior treatments tried, doses, duration, and why they failed
  • Current clinical status and bleeding risk
  • Why Tavalisse is medically necessary vs. alternatives

4. Monitor for Decision (Patient)

Check your Humana member portal or call member services. If you're a new Humana member already on Tavalisse, you have a 90-day transition period—but still submit documentation to avoid disruption.

5. If Approved: Fill at Specialty Pharmacy (Patient)

Tavalisse requires specialty pharmacy dispensing. Your approval will specify which pharmacy networks are covered.

Tip: For urgent cases where waiting could jeopardize your health, request expedited review for a decision within 24 hours.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Step therapy not met" Document specific prior therapies: steroid type, dose, duration, reason for discontinuation. Include TPO-RA trial with response data
"Not medically necessary" Strengthen clinical justification: bleeding episodes, impact on daily activities, contraindications to alternatives
"Insufficient documentation" Provide complete lab history, peripheral blood smear results, exclusion of secondary causes
"Prescriber not qualified" Ensure hematologist (not primary care) is prescribing with full credentials included

Appeals Playbook for Humana in Florida

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • How to file: Humana member portal or mail written request
  • Timeline: Decision within 30 days (60 days for payment appeals)
  • Required: Original denial letter, new supporting documentation, prescriber statement

Expedited Internal Appeal

  • When to use: Waiting would seriously jeopardize your health
  • Timeline: 72 hours for decision
  • How to request: Specifically state "expedited appeal" and provide medical urgency documentation

External Review (Florida)

If internal appeals fail, Florida offers independent external review through the Department of Financial Services.

  • Deadline: 4 months after final internal denial
  • Cost: Free to consumers
  • Process: Independent medical expert reviews case
  • Success rate: External reviews often favor consumers when clinical evidence is strong
Note: External review decisions are binding on Humana under Florida law.

Medical Necessity Letter Template

Clinician Corner: Essential Elements for Tavalisse Prior Authorization

To: Humana Prior Authorization Department
Re: [Patient Name], DOB [date], Member ID [number]
Request for: Tavalisse (fostamatinib) 100mg tablets

DIAGNOSIS: Chronic immune thrombocytopenia (ITP), ICD-10 D69.3
- Confirmed by repeated platelet counts <100,000/μL on [dates]
- Secondary causes excluded: negative HCV/HIV, normal peripheral smear, no medication-induced causes
- Current platelet count: [value] on [date]

PRIOR TREATMENT FAILURES:
1. Corticosteroids: [Prednisone/dexamethasone], [dose], [duration], [outcome/reason for discontinuation]
2. TPO Receptor Agonist: [Eltrombopag/romiplostim], [dose], [duration], [response/reason for discontinuation]
3. Other treatments if applicable: [IVIG, rituximab, etc.]

CLINICAL RATIONALE:
Patient has chronic, refractory ITP with [bleeding symptoms/risk factors]. Standard therapies have failed due to [lack of efficacy/intolerance]. Tavalisse represents appropriate next-line therapy per ASH guidelines.

REQUESTED THERAPY:
Tavalisse 100mg twice daily, may increase to 150mg twice daily based on response and tolerability.

Supporting documentation attached: Lab reports, treatment records, peripheral blood smear.

[Hematologist signature, NPI, contact information]

When Initial Approval Fails: Real Appeal Strategy

Building Your Appeal Case

New evidence wins appeals. Don't just resubmit the same information. Instead:

  1. Get updated labs showing persistent low platelets despite any interim treatments
  2. Document any bleeding episodes or functional impairment since the denial
  3. Request peer-to-peer review where your hematologist speaks directly with Humana's medical director
  4. Cite specific policy language from Humana's medical policies showing you meet criteria

Peer-to-Peer Review Script

When your doctor requests a peer-to-peer call:

"This is Dr. [Name] requesting peer-to-peer review for [patient name]'s Tavalisse prior authorization. The patient has documented chronic ITP with platelet count [value] despite trials of [specific prior therapies]. Per ASH guidelines and the medication's FDA labeling, this represents appropriate use after failure of standard therapies. I can provide additional clinical context if needed."

What Counterforce Health Sees Work

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by identifying the specific denial basis and crafting targeted, evidence-backed responses. For Tavalisse denials, the most effective appeals combine updated clinical documentation with direct references to the plan's own coverage policies—showing exactly how the patient meets the stated criteria.

Cost-Saving Options

Even with insurance approval, Tavalisse can have significant out-of-pocket costs:

Manufacturer Support

  • Rigel OneCare: Patient support program offering benefits investigation and potential copay assistance
  • Eligibility: Varies by insurance type and income

Foundation Assistance

  • Good Days: May provide grants for specialty medications
  • Patient Access Network Foundation: Copay assistance for qualifying patients

State Programs

Florida residents may qualify for additional assistance through state pharmaceutical programs, particularly if enrolled in Medicare with limited income.

Frequently Asked Questions

How long does Humana prior authorization take in Florida? Standard requests: 7 days maximum. Expedited requests for urgent medical needs: 24 hours. CMS regulations set these timelines.

What if Tavalisse isn't on Humana's formulary? You can request a formulary exception with strong medical necessity documentation. The process is the same as prior authorization but requires additional justification for why formulary alternatives won't work.

Can I get an expedited appeal if I'm having bleeding episodes? Yes. Document the bleeding episodes and have your hematologist state that delays in treatment could seriously jeopardize your health. Expedited appeals get decisions within 72 hours.

Does step therapy apply if I tried these medications outside Florida? Yes, prior treatment history from any location counts. Make sure your new Florida hematologist has complete records from your previous providers.

What happens if Humana's external review still denies coverage? You can file a complaint with Florida's Office of Insurance Regulation and explore other legal options, though this is rare when clinical criteria are clearly met.

Will Counterforce Health help with my specific case? Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing denial letters, plan policies, and clinical notes to draft evidence-backed rebuttals. Their platform helps identify the specific denial basis and creates point-by-point responses aligned to your plan's own rules.

From Our Advocates

We've seen Tavalisse approvals succeed even after initial denials when the appeal includes three key elements: updated platelet counts showing ongoing need, detailed documentation of why each prior therapy failed (not just that it was tried), and direct quotes from Humana's own medical policies showing the patient meets criteria. The peer-to-peer review often seals the deal when the hematologist can speak directly about bleeding risk and functional impact.

When to Escalate

If you've exhausted Humana's internal appeals and external review, contact:

Florida Department of Financial Services Consumer Helpline: 1-877-MY-FL-CFO (877-693-5236) File a complaint online

Include all denial letters, appeal submissions, medical records, and correspondence with Humana.

Disclaimer: This information is for educational purposes and is not medical advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly. For assistance with insurance appeals, consider consulting with patient advocacy services like Counterforce Health.

Sources & Further Reading

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