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

Tavalisse (Fostamatinib) Coverage with Blue Cross Blue Shield Illinois: Prior Authorization, Appeals, and Patient Assistance Guide

Answer Box: Getting Tavalisse Covered in Illinois

Tavalisse (fostamatinib) requires prior authorization from Blue Cross Blue Shield Illinois (BCBSIL) and is subject to step therapy requirements. To get coverage: (1) Your hematologist must document failed first-line ITP therapies like corticosteroids or IVIG, (2) Submit PA via Availity Provider Portal with complete clinical documentation, (3) If denied, appeal within 180 days using Illinois' strong external review process. Expect specialty tier costs ($300-800+ monthly) unless using manufacturer copay assistance.

First step today: Verify your specific plan's formulary status and PA requirements by logging into your BCBSIL member portal or calling the number on your insurance card.

Table of Contents

  1. Coverage Basics: Is Tavalisse Covered?
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Step Therapy and Clinical Criteria
  5. Costs and Financial Assistance
  6. Denials and Appeals in Illinois
  7. Annual Renewals
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics: Is Tavalisse Covered?

Yes, Tavalisse (fostamatinib) is covered by Blue Cross Blue Shield Illinois for FDA-approved indications, but it requires prior authorization and is typically placed on specialty tiers with higher out-of-pocket costs.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Must get approval before coverage BCBSIL PA Summary BCBSIL 2025
Formulary Tier Specialty Tier 5/6 Performance Drug List Prime Therapeutics
Step Therapy Must try preferred alternatives first Clinical Criteria BCBSIL Policy
Quantity Limits 60 tablets per 30 days Dispensing Limits BCBSIL 2024
Prescriber Requirement Hematologist or oncologist Clinical Documentation Plan Policy

Tavalisse is listed on BCBSIL's Performance Drug List but requires meeting strict medical necessity criteria for chronic immune thrombocytopenia (ITP) in adults who have had insufficient response to previous therapy.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Eligibility (Clinic Staff)
    • Use Availity Provider Portal to confirm PA requirements
    • Check member's specific formulary and benefit details
    • Timeline: 5-10 minutes
  2. Gather Clinical Documentation (Prescriber)
    • ICD-10 diagnosis code for chronic ITP (D69.3)
    • Documentation of prior therapy failures (corticosteroids, IVIG, TPO-RAs)
    • Current platelet count and bleeding risk assessment
    • Timeline: 1-2 business days
  3. Submit PA Request (Clinic Staff)
    • Complete request via Availity or BlueApprovR
    • Include all required clinical documentation
    • Timeline: 15-30 minutes
  4. Await Decision (Patient/Clinic)
    • Standard review: up to 15 business days
    • Expedited review: 24-72 hours (if urgent)
    • Decision notification sent to prescriber and patient
  5. If Approved (Patient)
    • Fill prescription at designated specialty pharmacy
    • Apply manufacturer copay assistance before first fill
    • Timeline: 2-5 business days for delivery

Required Clinical Documentation

Your hematologist must provide:

  • Diagnosis confirmation: Chronic ITP with platelet count <30,000/μL (or <50,000/μL with bleeding symptoms)
  • Prior therapy documentation: Failed response or intolerance to at least one first-line therapy
  • Treatment rationale: Why Tavalisse is medically necessary over alternatives
  • Monitoring plan: Regular platelet counts and liver function tests

Timeline and Urgency

Standard Timeline

  • PA submission to decision: Up to 15 business days
  • Appeal review: 30 business days for internal appeals
  • External review: 30 days total process in Illinois

Expedited Reviews

If you have severe bleeding risk or urgent clinical need:

  • Expedited PA: 24-72 hours
  • Urgent appeals: 72 hours for internal, 24-72 hours for external review
  • How to request: Mark "urgent" on forms and provide clinical justification
Tip: Illinois law requires faster processing for urgent cases. Document bleeding episodes or hospitalization risk to qualify for expedited review.

Step Therapy and Clinical Criteria

What Counts as Step Therapy?

BCBSIL typically requires documented trial and failure (or contraindication) of:

  1. First-line therapies:
    • Corticosteroids (prednisone, dexamethasone)
    • Intravenous immunoglobulin (IVIG)
    • Anti-D immunoglobulin (if Rh-positive)
  2. Second-line options:
    • Thrombopoietin receptor agonists (eltrombopag/Promacta, romiplostim/Nplate)
    • Rituximab
    • Immunosuppressants (azathioprine, mycophenolate)

Medical Necessity Criteria

Quote from BCBSIL Policy: "Coverage is provided for FDA-approved indications when medical necessity criteria are met, including documented inadequate response to or intolerance of preferred therapeutic alternatives."

Key requirements:

  • Age 18 or older
  • Chronic ITP diagnosis (>12 months duration)
  • Platelet count documentation
  • Bleeding symptoms or high bleeding risk
  • Hematologist prescription or consultation

Costs and Financial Assistance

Expected Out-of-Pocket Costs

Insurance Type Typical Monthly Cost With Copay Card
Commercial (Tier 5) $400-800+ $15-25
High-deductible plan Full cost until deductible met $15-25
After deductible 30-50% coinsurance $15-25

Manufacturer Assistance Programs

  1. Tavalisse Copay Assistance Program
    • Reduces copay to $15 per prescription
    • Annual benefit cap: $25,000
    • Enrollment: Tavalisse HCP Services
    • Phone: 1-833-744-3562
  2. Patient Assistance Program
    • Free medication for uninsured/underinsured patients
    • Income eligibility up to 500% of federal poverty level
    • Application through RxAssist
Note: Copay assistance is not available for government-funded insurance (Medicare, Medicaid). Patients with these plans should explore foundation grants and state programs.

Denials and Appeals in Illinois

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Step therapy not met Document failed prior therapies Treatment history, intolerance notes
Not medically necessary Provide clinical justification Bleeding episodes, platelet trends
Non-formulary Request formulary exception Medical necessity letter
Quantity exceeded Justify higher dose Physician attestation, dosing rationale

Illinois Appeals Process

Level 1: Internal Appeal

  • Deadline: 180 days from denial date
  • Timeline: 30 business days for decision (72 hours if urgent)
  • How to file: BCBSIL member portal or written request

Level 2: External Review

  • Deadline: 30 days from internal appeal denial
  • Timeline: 30 days total (24-72 hours if urgent)
  • How to file: Illinois Department of Insurance
  • Cost: Free to patients (insurer pays review fees)

Illinois-Specific Rights

Illinois provides stronger patient protections than many states:

  • Independent Review Organizations (IROs) must use board-certified specialists
  • Binding decisions: If IRO approves, BCBSIL must cover the treatment
  • Fast timelines: 5 business days for IRO decision after receiving records
  • Consumer assistance: Illinois Department of Insurance hotline at 877-527-9431
From Our Advocates: "We've seen Illinois patients successfully overturn specialty drug denials by providing comprehensive documentation of bleeding episodes and failed prior therapies. The state's external review process is particularly effective for FDA-approved medications like Tavalisse when clinical need is well-documented."

Annual Renewals

When to Reauthorize

  • Start renewal process: 30-45 days before current approval expires
  • Required updates: Current platelet counts, treatment response, ongoing medical necessity
  • Timeline: Same as initial authorization (up to 15 business days)

What Changes Year-to-Year

  • Formulary tier placement may change
  • Clinical criteria may be updated
  • Copay assistance programs require annual re-enrollment
  • New generic or biosimilar alternatives may affect step therapy requirements

Specialty Pharmacy Requirements

Why Specialty Pharmacy?

Tavalisse must be dispensed through BCBSIL's contracted specialty pharmacies due to:

  • High cost and complexity
  • Required patient monitoring and education
  • Special handling and storage requirements

BCBSIL Preferred Specialty Pharmacies

  • Prime Therapeutics Specialty
  • CVS Specialty (for certain plans)
  • Accredo Specialty Pharmacy

Contact your plan to confirm which specialty pharmacy is required for your specific coverage.

What to Expect

  • Home delivery: 2-5 business days
  • Patient education: Pharmacist consultation on first fill
  • Monitoring: Coordination with prescriber for lab results
  • Copay assistance: Specialty pharmacy can apply manufacturer cards

Troubleshooting Common Issues

Portal Problems

  • Availity down: Call provider services at number on member card
  • Missing forms: Check BCBSIL provider portal for current forms
  • Login issues: Contact Availity support or use alternative submission methods

Documentation Issues

  • Missing prior therapy records: Request from previous providers in advance
  • Lab results not current: Ensure platelet counts are within 30 days
  • Prescriber not in network: May require additional documentation or referral

Specialty Pharmacy Transfer

If your prescription was transferred to specialty pharmacy:

  • Normal process: All specialty medications require this
  • Timeline: 1-2 business days for transfer processing
  • What to do: Contact specialty pharmacy directly to coordinate delivery

Frequently Asked Questions

How long does BCBSIL prior authorization take for Tavalisse? Up to 15 business days for standard review, 24-72 hours for expedited requests when urgent medical need is documented.

What if Tavalisse is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Success rates are higher when clinical need is well-documented and alternatives have failed.

Can I request an expedited appeal in Illinois? Yes, if delay would seriously jeopardize your health. Illinois requires decisions within 72 hours for urgent internal appeals and 24-72 hours for external reviews.

Does step therapy apply if I failed therapies outside Illinois? Yes, documented treatment failures from any provider count toward step therapy requirements. Ensure your Illinois hematologist has complete treatment records.

What happens if my copay card reaches the $25,000 annual limit? Apply for the manufacturer's patient assistance program or explore foundation grants. Some patients transition to alternative therapies if cost becomes prohibitive.

How do I file a complaint against BCBSIL in Illinois? Contact the Illinois Department of Insurance at 877-527-9431 or file online. They can investigate coverage denials and help resolve disputes.

Can my primary care doctor prescribe Tavalisse? Most BCBSIL policies require prescription from or consultation with a hematologist or oncologist due to the complexity of ITP management.

What if I move to another state during treatment? Contact BCBSIL member services immediately. Coverage may change based on your new state's regulations and provider networks.

When to Escalate

Contact these Illinois resources if you need additional help:

  • Illinois Department of Insurance: 877-527-9431 for coverage disputes
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145 for insurance problems
  • Counterforce Health: Specializes in turning insurance denials into targeted, evidence-backed appeals for specialty medications like Tavalisse

Sources & Further Reading

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements to maximize approval chances.

Disclaimer: This guide provides educational information about insurance coverage and is not medical advice. Coverage policies change frequently, and individual circumstances vary. Always verify current requirements with your insurance plan and consult your healthcare provider for medical decisions. For personalized assistance with appeals and coverage issues, consider consulting with specialized advocacy services.

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