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

Work With Your Doctor to Get Tavalisse (Fostamatinib) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Prior Authorization Guide

Quick Answer: Getting Tavalisse Covered in Pennsylvania

To get Tavalisse (fostamatinib) covered by Blue Cross Blue Shield in Pennsylvania, you'll need prior authorization from a hematologist or oncologist documenting chronic ITP diagnosis, platelet count below 30,000/μL, and failure of first-line therapies (corticosteroids, IVIG, or TPO agonists). The fastest path: gather your treatment history, schedule a visit with your hematologist to complete the medical necessity letter, and submit through your Blue Cross provider portal. If denied, Pennsylvania's new external review process has overturned 53% of appeals. Start today: call your hematologist's office to schedule a consultation and request copies of your recent lab results.

Table of Contents

Set Your Goal: Understanding Approval Requirements

Tavalisse (fostamatinib disodium hexahydrate) requires prior authorization from all Blue Cross Blue Shield plans, including those in Pennsylvania. Your partnership with a hematologist or oncologist is essential—this isn't a medication your primary care physician can typically prescribe.

Core eligibility criteria across Blue Cross plans:

  • Chronic immune thrombocytopenia (ITP) diagnosis in adults 18+
  • Prescription from or consultation with a hematologist/oncologist
  • Current platelet count below 30,000/μL (or below 50,000/μL with active bleeding)
  • Documented failure, intolerance, or contraindication to at least one first-line therapy

The approval process typically takes 72 hours to 7 business days for standard requests, with expedited options available for urgent situations.

Prepare for Your Visit

Your hematologist needs a complete picture of your ITP journey to write a compelling medical necessity letter. Come prepared with:

Symptom Timeline

  • When did your low platelet count first appear?
  • What symptoms led to your ITP diagnosis (bruising, bleeding, fatigue)?
  • How have symptoms affected your daily activities and quality of life?

Treatment History Documentation

  • Corticosteroids: Which ones (prednisone, dexamethasone), dosages, duration, and response
  • IVIG treatments: Dates, doses, and platelet count responses
  • TPO receptor agonists: Trials of eltrombopag (Promacta), romiplostim (Nplate), or avatrombopag (Doptelet)
  • Other therapies: Rituximab, splenectomy consideration, or immunosuppressants

Side Effects and Intolerances Document specific problems with previous treatments: steroid-induced diabetes, IVIG headaches, TPO agonist liver enzyme elevations, or other contraindications that make Tavalisse the appropriate next step.

Build Your Evidence Kit

Gather supporting documentation before your appointment:

Recent Laboratory Results

  • Complete blood count (CBC) with platelet count from the past 30 days
  • Liver function tests (ALTs, ASTs) to establish baseline
  • Blood pressure readings if you have hypertension history

Clinical Guidelines Support The ASH (American Society of Hematology) guidelines recommend thrombopoietin receptor agonists as second-line therapy after corticosteroid failure. Tavalisse offers an oral alternative when TPO agonists aren't suitable.

Medication History Summary Create a simple timeline: "January 2023: Prednisone 60mg daily × 4 weeks, platelets increased to 45,000 but returned to 15,000 after taper. March 2023: IVIG 1g/kg × 2 days, minimal response, platelets remained below 20,000."

Medical Necessity Letter Structure

Your hematologist's letter should follow this evidence-based structure:

Patient Identification and Diagnosis

  • Full name, date of birth, insurance ID
  • ICD-10 code for chronic ITP (D69.3)
  • Date of initial diagnosis and confirming specialist

Clinical Rationale "Mr./Ms. [Patient] has chronic immune thrombocytopenia with current platelet count of [X]/μL documented on [date]. Despite adequate trials of [list specific therapies with dates and outcomes], platelet count remains dangerously low with [describe bleeding risk or symptoms]."

Prior Treatment Documentation Detail each therapy systematically:

  • Prednisone 1-2 mg/kg daily for [duration] with [specific outcome]
  • IVIG [dose] on [dates] with [platelet response and duration]
  • TPO agonist trial: [drug name, dose, duration, reason for discontinuation]

Medical Necessity Statement "Tavalisse is medically necessary as this patient meets FDA-approved indication criteria for adults with chronic ITP who have had insufficient response to previous therapy. The oral SYK inhibitor mechanism offers a different therapeutic approach when TPO agonists are contraindicated or ineffective."

Monitoring Plan Include the required monitoring schedule: monthly liver function tests, blood pressure checks, and platelet count monitoring per FDA labeling.

Support Your Provider with Peer-to-Peer

If Blue Cross requests a peer-to-peer review, help your hematologist prepare:

Offer Scheduling Flexibility "I'm available for the peer-to-peer call during your office hours and can adjust my schedule to accommodate the review."

Prepare a Case Summary Create a one-page summary: diagnosis date, previous treatments with specific dates and outcomes, current symptoms, and why Tavalisse is the appropriate next step.

Key Talking Points for Your Doctor

  • Emphasize failed first-line therapies with specific details
  • Reference ASH guidelines supporting second-line therapy options
  • Highlight Tavalisse's unique mechanism as an oral SYK inhibitor
  • Address safety monitoring plan

After Your Visit: Documentation Strategy

Save Everything

  • Copy of the medical necessity letter
  • Lab results referenced in the letter
  • Prior authorization submission confirmation
  • Any communication from Blue Cross

Portal Communication Use your patient portal to message your hematologist's office: "Please confirm the PA was submitted to Blue Cross and provide the reference number for my records."

Track Submission Most Blue Cross plans provide online PA tracking. Log into your member portal within 24-48 hours to verify the request appears in your authorization history.

Respectful Persistence Strategy

Week 1: If no response after 5 business days, call Blue Cross member services to confirm receipt and ask for status update.

Week 2: Contact your hematologist's office to request they follow up directly with the medical director or pharmacy team.

Week 3: If still pending, escalate through Blue Cross supervisory channels and consider expedited review if your condition is worsening.

Maintain Documentation Keep notes of every call: date, representative name, reference numbers, and next steps promised.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Blue Cross plans Blue Cross formulary
Prescriber Hematologist or oncologist Plan-specific PA criteria
Diagnosis Chronic ITP (adults 18+) FDA labeling
Platelet Count <30,000/μL or <50,000/μL with bleeding Medical necessity guidelines
Prior Therapies Failed corticosteroids, IVIG, or TPO agonists ASH treatment guidelines
Processing Time 72 hours standard, 24 hours expedited Blue Cross member handbook

Appeals Process for Pennsylvania

Pennsylvania offers strong consumer protections for insurance appeals:

Internal Appeal (First Level)

  • File within 180 days of denial
  • Blue Cross has 30 days to respond (15 days for urgent requests)
  • Submit through member portal or mail to address on denial letter

External Review (Pennsylvania Advantage) Pennsylvania's new Independent External Review program has overturned 53% of appeals since launching in 2024. After completing internal appeals:

  • Submit request through Pennsylvania Insurance Department website
  • No cost to consumers
  • Independent Review Organization (IRO) decides within 45 days
  • Expedited reviews for urgent situations decided within 72 hours

Required Documents for Appeals

  • Original denial letter with Final Adverse Benefit Determination
  • Medical necessity letter from hematologist
  • Supporting lab results and treatment history
  • Any additional clinical evidence

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Not prescribed by specialist" Obtain prescription from hematologist/oncologist
"Inadequate prior therapy trial" Document specific dates, doses, and outcomes of failed treatments
"Insufficient platelet count documentation" Provide recent CBC with differential showing platelets <30,000/μL
"Alternative therapies available" Detail contraindications or failures with TPO agonists, explain why Tavalisse's mechanism is needed
"Not medically necessary" Reference FDA labeling and ASH guidelines; emphasize bleeding risk

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients and clinicians identify denial reasons and draft point-by-point rebuttals aligned to each plan's specific rules, pulling the right citations and clinical evidence to strengthen medical necessity arguments.

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Pennsylvania? Standard requests receive responses within 72 hours to 7 business days. Expedited requests for urgent situations are processed within 24 hours.

What if Tavalisse is non-formulary on my Blue Cross plan? You can request a formulary exception through your plan's standard process, typically requiring the same medical necessity documentation as prior authorization.

Can I request an expedited appeal if my platelets are critically low? Yes. If your platelet count is below 10,000/μL or you have active bleeding, request expedited processing for both prior authorization and appeals.

Does step therapy apply if I failed treatments in another state? Medical records from any licensed provider should count toward step therapy requirements. Ensure your new hematologist documents the previous treatment failures.

What's the typical cost of Tavalisse without insurance? WAC (Wholesale Acquisition Cost) pricing suggests approximately $14,000-$16,000 per 60-tablet bottle. Rigel Pharmaceuticals offers patient assistance programs for eligible individuals.

How do I find a hematologist if I don't have one? Contact your Blue Cross member services for in-network hematologists or use their online provider directory. Many require referrals from primary care physicians.

From our advocates: We've seen successful Tavalisse appeals when patients work closely with their hematology team to document not just treatment failures, but the specific impact on quality of life. One effective approach involves creating a timeline showing how each previous therapy affected daily activities—this helps medical directors understand why standard treatments aren't sufficient. Remember, persistence and thorough documentation often make the difference between approval and denial.

For complex cases or additional support, Counterforce Health helps patients and specialty pharmacies navigate the prior authorization process by analyzing denial letters and crafting targeted appeals with the specific evidence each payer requires.

Sources & Further Reading

This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for specific coverage questions. For additional help with Pennsylvania insurance appeals, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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