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

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

Answer Box: Getting Tavalisse Covered by Humana in Pennsylvania

Tavalisse (fostamatinib) is not on Humana's standard formulary in Pennsylvania and requires prior authorization or a formulary exception. Your fastest path to approval:

  1. Confirm your diagnosis: Chronic ITP with platelet count <30,000/μL documented by a hematologist
  2. Document step therapy: Failed trials of corticosteroids, IVIG, and at least one TPO receptor agonist
  3. Submit formulary exception: Through Humana's provider portal or member services within 65 days of any denial

Start today by calling Humana member services (number on your ID card) to request the prior authorization form and confirm your plan's specific requirements.

Table of Contents

Humana Plan Types & Coverage Implications

Humana operates different plan types in Pennsylvania, each with distinct coverage rules for Tavalisse:

Medicare Advantage Plans: Predominant in Humana's Pennsylvania portfolio. These plans follow federal Medicare Part D guidelines for specialty drugs, with 65-day appeal windows and standardized prior authorization processes.

Commercial Plans: Less common but available through employers. These follow Pennsylvania state insurance laws and may have different formulary placement and appeal rights.

Medicaid Plans: Limited Humana presence in Pennsylvania Medicaid, but if applicable, would follow Pennsylvania's Medicaid preferred drug list requirements.

Note: Your specific plan type determines which appeal pathway you'll use if initially denied.

Tavalisse Formulary Status & Alternatives

Based on publicly available 2024-2025 Humana formularies, Tavalisse does not appear on standard Humana Medicare Advantage formularies in Pennsylvania. This means:

  • Non-formulary status: Requires a formulary exception request
  • No standard tier placement: If approved, likely placed at highest cost-sharing tier
  • Prior authorization mandatory: Even with exception approval

Preferred Alternatives on Humana Formularies

Humana typically covers these ITP treatments with lower barriers:

  • Eltrombopag (Promacta) - TPO receptor agonist, Tier 3-4
  • Romiplostim (Nplate) - TPO receptor agonist, specialty tier
  • Generic corticosteroids - Tier 1-2
  • IVIG products - Medical benefit coverage

Prior Authorization Requirements

Clinical Documentation Required

Prescriber Requirements:

Diagnosis Documentation:

  • Chronic immune thrombocytopenia (ICD-10: D69.3)
  • Disease duration >12 months or persistent/chronic classification
  • Recent platelet count <30,000/μL (within 30 days of submission)

Step Therapy Requirements: Based on standard Humana policies, patients must have documented:

  1. Corticosteroid trial (minimum 4 days of prednisone or equivalent)
  2. IVIG therapy trial or contraindication
  3. TPO receptor agonist trial (eltrombopag or romiplostim for ≥60 days)
  4. Splenectomy contraindication or post-splenectomy relapse

Coverage at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans PA form + clinical notes Humana PA Portal
Prescriber Hematologist required Specialty credentials Standard policy
Lab Values Platelet count <30,000/μL Recent CBC (within 30 days) Clinical guidelines
Step Therapy 3+ prior therapies Treatment history with dates PA criteria
Approval Duration 6 months initial Clinical response data for renewal Standard policy

Specialty Pharmacy Network

Tavalisse requires dispensing through Humana's specialty pharmacy network. Key requirements:

Dispensing Protocols:

  • Maximum 300 mg/day (two 150 mg tablets)
  • 30-day supply limits initially
  • Mandatory clinical monitoring documentation

Network Pharmacies:

  • Humana Pharmacy Solutions (primary specialty partner)
  • Select retail specialty pharmacies in network
  • Verify current network status before prescribing

Patient Setup:

  1. Prescriber submits PA approval
  2. Specialty pharmacy contacts patient for enrollment
  3. Coordination of benefits and copay assistance verification
  4. Home delivery or pickup arrangement

Cost-Share Considerations

Estimated Costs:

  • Wholesale acquisition cost: ≈$14,000-$16,000 per 60-tablet bottle
  • Patient responsibility varies by plan design and approval tier

Financial Assistance Options:

Important: This is educational information only. Consult your plan documents for specific cost-sharing details.

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Complete medical history with ITP diagnosis
    • Laboratory results (CBC with platelet count)
    • Prior therapy documentation with dates and outcomes
  2. Contact Humana (Patient)
    • Call member services number on ID card
    • Request formulary exception for Tavalisse
    • Obtain PA form and submission instructions
  3. Complete Prior Authorization (Prescriber)
    • Submit through Humana provider portal or fax
    • Include all required clinical documentation
    • Timeline: 7 days for standard review, 72 hours for expedited
  4. Specialty Pharmacy Enrollment (If Approved)
    • Humana will coordinate with specialty pharmacy
    • Patient enrollment call within 1-2 business days
    • First fill coordination and delivery setup

Medical Necessity Letter Checklist

When submitting clinical documentation, ensure your letter includes:

  • Problem statement: Chronic ITP with current platelet count and bleeding risk
  • Prior treatments: Specific medications, doses, duration, and reason for discontinuation
  • Clinical rationale: Why Tavalisse is appropriate based on FDA labeling
  • Monitoring plan: Laboratory follow-up and safety assessments
  • Guideline support: Reference to ASH 2019 ITP guidelines

Appeals Process in Pennsylvania

Internal Appeals (Humana)

Level 1 - Redetermination:

  • Deadline: 65 days from denial notice
  • Decision timeline: 7 days standard, 72 hours expedited
  • How to file: Online portal, phone, or written request

Level 2 - Reconsideration:

  • Who decides: Independent Review Entity (IRE) for Medicare plans
  • Deadline: 60 days from Level 1 denial
  • Decision timeline: 7 days for benefits, 14 days for payment

Pennsylvania External Review

If internal appeals are unsuccessful, Pennsylvania residents have additional rights:

Pennsylvania Insurance Department External Review:

Timeline for External Review:

  • Standard review: 45 days from IRO assignment
  • Expedited review: 72 hours for urgent cases
  • Additional information: 15 days to submit supporting documents
From our advocates: In complex specialty drug cases like Tavalisse, we've seen the strongest appeals combine detailed clinical rationale with peer-reviewed evidence and clear documentation of step therapy compliance. Success often comes down to presenting a complete clinical picture that addresses the specific denial reason.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Step therapy not completed" Document all prior treatments with dates Pharmacy records, physician notes showing trials and failures
"Not prescribed by specialist" Obtain hematology consultation Specialist consultation note or co-signature
"Insufficient lab documentation" Submit recent platelet counts CBC results within 30 days of request
"Non-formulary drug" Request formulary exception Medical necessity letter explaining why alternatives failed
"Experimental/investigational" Cite FDA approval and guidelines FDA label and clinical evidence

When to Escalate to State Review

Contact the Pennsylvania Insurance Department if:

  • Humana fails to respond within required timeframes
  • You believe proper procedures weren't followed
  • Internal appeals are exhausted and coverage is still denied
  • You need assistance navigating the appeals process

Pennsylvania Insurance Department Consumer Services:

  • Phone: Available on insurance.pa.gov
  • Online complaint portal for formal grievances
  • Free assistance through Pennsylvania Health Law Project

At Counterforce Health, we help patients and clinicians 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.

FAQ

How long does Humana prior authorization take in Pennsylvania? Standard PA decisions: 7 days. Expedited reviews (for urgent medical need): 72 hours. Medicare plans follow federal timelines regardless of state.

What if Tavalisse is completely non-formulary on my plan? Request a formulary exception through Humana member services. You'll need medical necessity documentation showing why formulary alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if your health condition requires urgent treatment. Both PA requests and appeals can be expedited with physician documentation of medical urgency.

Does step therapy apply if I failed treatments in another state? Yes, prior therapy documentation from any provider/state counts toward step therapy requirements. Ensure records clearly document treatment failures or intolerance.

What happens if my appeal is denied at all levels? For Medicare plans, you can request an Administrative Law Judge hearing if the dollar amount meets the threshold ($180 in 2024). For all plans, Pennsylvania's external review provides an additional pathway.

How much will Tavalisse cost if approved? Cost depends on your plan's specialty tier copay or coinsurance. Contact Humana member services for your specific cost-sharing details and ask about manufacturer assistance programs.

Can my doctor request a peer-to-peer review? Yes, most Humana plans allow prescribers to request a clinical discussion with the plan's medical director when a PA is denied. This can be particularly helpful for complex cases.

What if I need Tavalisse while my appeal is pending? You may need to pay out-of-pocket temporarily. Keep all receipts – if your appeal succeeds, Humana may provide retroactive coverage. Some manufacturer programs may provide temporary assistance.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting with qualified advocates or legal professionals.

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