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

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

Answer Box: Getting Tavalisse Covered by Humana in Virginia

Fastest Path: Submit prior authorization through your hematologist with documented ITP diagnosis (ICD-10 D69.3), platelet count <30,000/μL, and evidence of failed corticosteroids plus thrombopoietin receptor agonist therapy. If denied, appeal within 65 days using Humana's internal process, then request Virginia external review via Form 216-A within 120 days.

Start Today: Contact your hematologist's office to confirm they've submitted complete PA documentation to Humana, including recent labs and prior treatment records.

Table of Contents

Why Virginia State Rules Matter

Virginia's insurance laws provide important protections that work alongside Humana's policies to help you get Tavalisse (fostamatinib) approved. Understanding these rules can make the difference between a quick approval and months of appeals.

Key Virginia Protections:

  • Step therapy exceptions must be decided within 72 hours (24 hours for urgent cases) under Virginia Code § 38.2-3407.9:05
  • External review rights through the Virginia State Corporation Commission Bureau of Insurance
  • Managed Care Ombudsman assistance at 1-877-310-6560 for appeal guidance

Virginia's external review process applies to fully insured Humana plans but not Medicare Advantage (which follows federal Medicare appeal rules). If you're unsure which type of plan you have, check your insurance card or call Humana member services.

Coverage at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all Humana plans Complete PA form via provider Humana PA Lists
Prescriber Hematologist or ITP specialist Medical license verification Humana PA Requirements
Diagnosis Chronic ITP (ICD-10 D69.3) Clinical notes, diagnosis codes Humana Coverage Criteria
Lab Values Platelet count <30,000/μL Recent lab results (within 30 days) Plan-specific criteria
Step Therapy Failed steroids + TPO agonist Treatment records, failure documentation Step therapy protocols
Appeal Deadline 65 days (Medicare) / varies (commercial) Denial letter, supporting docs Plan documents

Humana's Prior Authorization Requirements

Tavalisse requires prior authorization across all Humana plans due to its specialty status and high cost (approximately $14,000-$16,000 per month). Here's what Humana specifically looks for:

Required Documentation:

  1. Specialist Prescriber: Must be prescribed by a hematologist or physician specializing in ITP treatment
  2. Confirmed Diagnosis: Chronic primary immune thrombocytopenia with ICD-10 code D69.3
  3. Laboratory Evidence: Platelet count documented at <30,000/μL (or <50,000/μL with bleeding risk)
  4. Step Therapy Compliance: Evidence of inadequate response to:
    • Corticosteroids (prednisone or equivalent)
    • At least one thrombopoietin receptor agonist (eltrombopag or romiplostim)
  5. Clinical Rationale: Detailed explanation of why Tavalisse is medically necessary
Clinician Corner: Medical Necessity Letter Checklist

Your hematologist's letter should include:Patient's ITP history and chronicitySpecific prior treatments tried, doses, duration, and outcomesCurrent platelet count and bleeding symptoms/riskCitation of FDA-approved indication for chronic ITPMonitoring plan for liver function and blood pressureReference to ASH guidelines or other relevant hematology standards

Step-by-Step: Fastest Path to Approval

1. Confirm Your Hematologist is In-Network

Who does it: You or your clinic Timeline: Same day How: Use Humana's provider directory or call member services

2. Gather Required Documentation

Who does it: Your hematologist's office Documents needed:

  • Complete treatment history
  • Recent CBC with platelet count
  • Documentation of steroid trial and TPO agonist failure
  • ITP diagnosis confirmation

3. Submit Prior Authorization

Who does it: Your hematologist's office How: Humana provider portal or fax to 1-877-486-2621 Timeline: Allow 5-7 business days for standard review

4. Follow Up on Status

Who does it: You or your clinic When: After 5 business days if no response How: Call Humana provider services or check portal status

5. Request Expedited Review if Urgent

Who does it: Your hematologist When: If bleeding risk or hospitalization concern Timeline: 72 hours for urgent determinations

Virginia's Step Therapy Protections

Virginia law provides strong protections when Humana requires you to try other medications first. Under Virginia Code § 38.2-3407.9:05, you can request a step therapy exception if:

Exception Criteria:

  • Contraindication: The required step therapy drug is contraindicated for you
  • Ineffectiveness: Based on your clinical characteristics, the drug would be ineffective
  • Previous Failure: You've tried the step therapy drug and had to stop due to lack of efficacy or adverse events
  • Current Success: You're stable on Tavalisse under a previous plan

Timeline Requirements:

  • Standard requests: 72 hours for decision
  • Urgent cases: 24 hours for decision
  • Drug samples don't count as completed trials

When requesting an exception, have your doctor explicitly reference the applicable Virginia law criteria and provide detailed clinical documentation.

Appeals Process and Timelines

If your initial prior authorization is denied, Virginia provides multiple levels of appeal protection:

Internal Appeals (First Step)

Timeline: 65 days from denial notice (Medicare plans) or per plan documents (commercial) How to file:

  • Call Humana member services (number on your card)
  • Submit written appeal with medical records
  • Request peer-to-peer review with hematologist

Virginia External Review (After Internal Appeals)

Eligibility: Fully insured commercial plans (not Medicare Advantage) Timeline: 120 days from final internal denial How to file: Submit Form 216-A to Virginia Bureau of Insurance Contact:

External Review Timeline:

  • Bureau notifies Humana within 1 business day
  • Humana has 5 days for preliminary review
  • Independent reviewer assigned within 1 day
  • You have 5 days to submit additional information
  • Decision within 45 days (72 hours if expedited)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not prescribed by specialist" Confirm hematologist credentials Medical license, board certification
"Step therapy not completed" Document previous failures Treatment records, adverse event notes
"Insufficient platelet count documentation" Submit recent labs CBC within 30 days showing <30,000/μL
"Medical necessity not established" Enhanced clinical letter Bleeding symptoms, functional impact
"Non-formulary drug" Request formulary exception Comparative effectiveness data

Scripts and Templates

Patient Phone Script for Humana

"Hello, I'm calling about a prior authorization denial for Tavalisse for chronic ITP. My member ID is [ID number]. I'd like to request an internal appeal and speak with someone about the specific denial reasons. Can you also tell me if a peer-to-peer review with my hematologist is available?"

Clinic Staff Script for Expedited Review

"This is [Name] from [Clinic] calling about an urgent prior authorization for Tavalisse. The patient has chronic ITP with a platelet count of [number] and active bleeding concerns. We need expedited review under your urgent criteria. What additional documentation do you need immediately?"

When to Contact Virginia Regulators

Contact the Virginia Managed Care Ombudsman or Bureau of Insurance if:

  • Humana isn't following required timelines
  • You're having trouble understanding the appeal process
  • You believe Humana is violating Virginia insurance laws

Virginia Managed Care Ombudsman: 1-877-310-6560 Bureau of Insurance Consumer Services: 1-800-552-7945

The Ombudsman can provide free assistance with appeals and sometimes resolve issues informally before you need external review.

Cost Assistance Programs

While pursuing coverage approval, explore these cost assistance options:

Manufacturer Support:

Foundation Grants:

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

Virginia-Specific Resources:

  • Virginia Medicaid may cover Tavalisse for eligible patients
  • Free clinics through Virginia Association of Free and Charitable Clinics
From Our Advocates: We've seen several Virginia patients succeed with Tavalisse appeals by ensuring their hematologist included specific platelet trends over time, not just a single lab value. The combination of documented bleeding events plus functional impact (like inability to work or care for family) often strengthens the medical necessity case. Remember, this is a composite example for educational purposes only.

FAQ

How long does Humana prior authorization take in Virginia? Standard PA decisions: 5-7 business days. Expedited reviews for urgent cases: 72 hours. Virginia law requires step therapy exceptions within 72 hours (24 hours if urgent).

What if Tavalisse isn't on Humana's formulary? Request a formulary exception with your PA submission. Include comparative effectiveness data showing why alternatives aren't appropriate for your specific case.

Can I get expedited appeal if I'm having bleeding episodes? Yes. Have your hematologist document active bleeding or high bleeding risk. Both Humana and Virginia external review offer expedited timelines for urgent medical situations.

Does Virginia step therapy protection apply to Medicare Advantage? No. Medicare Advantage follows federal rules. However, you can still request exceptions based on medical necessity through Medicare's appeal process.

How much does Tavalisse cost without insurance? Approximately $14,000-$16,000 per month based on wholesale acquisition cost data. This makes prior authorization approval critical for affordability.

What counts as "failed" prior therapy for step therapy? Documented inadequate platelet response, intolerable side effects, or contraindications. Drug samples don't count as completed trials under Virginia law.

Can I appeal if my employer plan is self-funded? Self-funded ERISA plans may opt into Virginia's external review process, but many follow federal appeal procedures instead. Check with your benefits administrator.

How do I know if my Humana plan is fully insured or self-funded? Check your insurance card or Summary Plan Description. Fully insured plans are regulated by Virginia; self-funded plans fall under federal ERISA rules.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Our platform identifies the specific denial basis and drafts point-by-point responses aligned with each plan's requirements, pulling the right medical evidence and citations to support your case.

When dealing with complex specialty drug approvals like Tavalisse, having expert support can make the difference between approval and denial. Counterforce Health provides the specialized knowledge and documentation strategies that help patients get the medications they need.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan and medical circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. Coverage policies and requirements may change; verify current information with official sources.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.