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

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

Answer Box: Getting Tavalisse Covered by UnitedHealthcare in Texas

UnitedHealthcare requires prior authorization for Tavalisse (fostamatinib) in adults with chronic ITP who had insufficient response to prior treatments like corticosteroids, immunoglobulins, or TPO receptor agonists. Your hematologist submits electronically via the UHC Provider Portal with diagnosis confirmation (ICD-10 D69.3), platelet trends, and prior therapy failures. Processing takes 24-72 hours; denials can be appealed within 180 days through internal review, then external review via Texas Department of Insurance if needed.

First step today: Call UnitedHealthcare member services at the number on your insurance card to confirm Tavalisse's formulary status and verify your specialty pharmacy network requirements.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Understanding Your Costs and Savings Options
  4. When Prior Authorization Gets Denied
  5. Appeals Process in Texas
  6. Specialty Pharmacy Coordination
  7. Annual Renewal Planning
  8. Helpful Scripts and Templates
  9. FAQ: Common Questions

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Tavalisse prescriptions UHC PA Policy
Prescriber Must be a hematologist UHC Provider Portal
Diagnosis Chronic ITP (ICD-10 D69.3) for ≥12 months FDA labeling, clinical records
Prior Therapies Failed/inadequate response to steroids, IVIG, or TPO-RAs Medical chart documentation
Platelet Count Documented <30,000/μL trends over 3-6 months Recent lab results
Specialty Pharmacy Must use UHC network specialty pharmacy OptumRx or approved alternatives
Initial Approval 12 months with reauthorization required UHC policy documentation

Step-by-Step: Fastest Path to Approval

1. Confirm Your Coverage Details

Who does it: You (patient)
Timeline: 15 minutes
Call UnitedHealthcare member services and ask:

  • "Is Tavalisse on my formulary?"
  • "What's my specialty pharmacy copay?"
  • "Do I need a specialty pharmacy?"

2. Gather Required Documentation

Who does it: Your hematologist's office
Timeline: 1-2 days
Collect these records:

  • Chronic ITP diagnosis with duration (≥12 months)
  • Platelet count trends showing <30,000/μL
  • Prior therapy records (corticosteroids, IVIG, TPO-RAs)
  • Recent labs: CBC, liver function tests, blood pressure readings

3. Submit Prior Authorization

Who does it: Hematologist
Timeline: 24-72 hours for decision
Submit electronically through the UHC Provider Portal including:

  • Completed PA form
  • Medical necessity letter
  • All supporting clinical documentation

4. Track Your Request

Who does it: You or your doctor's office
Timeline: Ongoing
Use the Provider Portal or call UnitedHealthcare to check status with your confirmation number.

5. Address Any Information Requests

Who does it: Doctor's office
Timeline: Respond within 14 days
Provide any additional documentation requested promptly to avoid delays.

Tip: Electronic submissions through the Provider Portal are processed fastest, often within 24 hours compared to 3-5 days for fax submissions.

Understanding Your Costs and Savings Options

Tavalisse typically costs $14,000-$16,000 per month without insurance coverage. Here's how to minimize your out-of-pocket expenses:

Manufacturer Copay Assistance

Rigel OneCare Program reduces costs to as little as $0-$15 per prescription for commercially insured patients, with an annual cap of $15,000.

Eligibility:

  • Must have commercial insurance (not Medicare/Medicaid)
  • US resident
  • Prescription filled in US/Puerto Rico

How to apply: Visit tavalisse.com/support or call 833-744-3563.

Foundation Assistance Programs

  • PAN Foundation: Up to $10,000 per year for ITP medication copays
  • HealthWell Foundation: Up to $2,300 during 12-month grant periods for patients up to 300-500% of Federal Poverty Level

Patient Assistance Program

For uninsured or underinsured patients, Rigel OneCare provides free Tavalisse for households earning ≤500% of Federal Poverty Level.

When Prior Authorization Gets Denied

Common denial reasons and how to address them:

Denial Reason How to Fix It Timeline
Incomplete prior therapy documentation Submit detailed chart notes showing doses, duration, and outcomes 3-7 days
Non-hematologist prescriber Add hematology consultation or co-signature 1-2 weeks
Missing recent labs Provide CBC, liver function tests, BP within 30 days 2-5 days
Insufficient platelet documentation Submit 3-6 months of platelet trends <30,000/μL 1 week
From our advocates: We've seen cases where patients were initially denied because their prior therapy documentation didn't specify exact doses and duration. When the hematologist resubmitted with detailed pharmacy records showing "prednisone 1mg/kg daily for 4 weeks with inadequate response," the approval came through within 48 hours.

Appeals Process in Texas

If your prior authorization is denied, Texas law provides strong patient rights for appeals.

Internal Appeals (Level 1)

Deadline: 180 days from denial date
Timeline: 30 days for standard review, 72 hours for expedited
How to submit: UnitedHealthcare Provider Portal (required)

Required documents:

  • Completed appeal form
  • Medical necessity letter from hematologist
  • All clinical documentation supporting the request
  • Copy of original denial letter

Peer-to-Peer Review

Deadline: Within 21 days of denial
Timeline: Scheduled within 3 business days
Your hematologist can request a direct conversation with UnitedHealthcare's medical director to discuss the clinical rationale.

External Review (Texas Department of Insurance)

When available: After internal appeals are exhausted
Deadline: 4 months from final internal denial
Timeline: 20 days standard, 5 days expedited
Cost: Free to patients

Contact: Texas Department of Insurance at 1-800-252-3439

The external review has approximately a 50% success rate when comprehensive documentation contradicts the insurer's denial.

Specialty Pharmacy Coordination

Tavalisse must be dispensed through UnitedHealthcare's specialty pharmacy network. Here's what you need to know:

OptumRx Specialty Pharmacy

  • Primary specialty pharmacy for UnitedHealthcare
  • Handles prior authorization coordination
  • Provides 30-day supplies typically
  • Offers home delivery and clinical support

Key Coordination Tips

  1. Confirm network status before your first fill
  2. Transfer existing prescriptions if switching from another pharmacy
  3. Set up automatic refills to avoid gaps in therapy
  4. Monitor for formulary changes during annual updates

Annual Renewal Planning

Tavalisse approvals are typically granted for 12-month periods. Plan ahead:

60 Days Before Expiration

  • Schedule appointment with hematologist
  • Gather updated lab results
  • Document clinical response (platelet improvements, bleeding episodes)

Required Renewal Documentation

  • Evidence of positive clinical response
  • Updated platelet counts
  • Adherence confirmation
  • Safety monitoring results (liver function, blood pressure)

What Can Change

  • Formulary tier placement (January 1 annually)
  • Quantity limits
  • Site-of-care requirements
  • Copay amounts

Helpful Scripts and Templates

Patient Script for UnitedHealthcare

"Hi, I'm calling about prior authorization for Tavalisse for chronic ITP. My member ID is [X]. Can you tell me the status of my request submitted on [date] with confirmation number [X]? If it's been denied, I'd like to understand the specific reasons and next steps for appeal."

Clinic Script for Peer-to-Peer Request

"I'm requesting a peer-to-peer review for patient [name] whose Tavalisse prior authorization was denied on [date]. The patient has chronic ITP with platelet count [X]/μL despite [list prior therapies]. I can provide additional clinical rationale directly to your medical director."

For patients navigating complex insurance approvals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify the specific denial basis and draft point-by-point rebuttals aligned with the plan's own rules, helping patients, clinicians, and specialty pharmacies get prescription drugs approved more efficiently.

FAQ: Common Questions

How long does UnitedHealthcare prior authorization take for Tavalisse in Texas? Electronic submissions typically take 24-72 hours. Complex cases may take up to 3 business days. Expedited reviews are available if delays would jeopardize your health.

What if Tavalisse isn't on my formulary? You can request a formulary exception as part of the prior authorization process. Your hematologist will need to provide medical justification for why formulary alternatives aren't appropriate.

Can I get expedited approval if I'm hospitalized? Yes, urgent cases qualify for 72-hour review timelines. Your doctor must document that delays would risk your health or safety.

Does step therapy apply in Texas? For fully insured UnitedHealthcare plans, step therapy requirements may apply unless you qualify for an exception. Self-insured employer plans may have different rules.

What happens if I move out of Texas? Your coverage will follow your plan's rules, but appeal rights may change. Contact UnitedHealthcare to understand how relocation affects your coverage.

How much will I pay out-of-pocket? This depends on your specific plan's specialty tier copay. With manufacturer assistance, commercially insured patients often pay $0-$15 per prescription.

Can my primary care doctor prescribe Tavalisse? UnitedHealthcare requires the prescriber to be a hematologist for Tavalisse prior authorizations.

What if I'm on Medicare? Medicare Part D follows different rules than commercial insurance. The appeals process involves Medicare-specific levels and timelines.

When dealing with insurance coverage challenges, services like Counterforce Health can help streamline the appeals process by providing evidence-backed documentation that addresses payers' specific concerns and requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for the most current coverage policies and medical recommendations. Coverage policies may vary by plan type and can change without notice.

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