CurrentAvMedPolicy N/A

Prior authorization for Tavalisse (fostamatinib)

This form governs prior authorization and step-edit requests for Tavalisse (fostamatinib) for AvMed members, specifying required clinical criteria, documentation, and authorization periods for prescribers and office staff submitting requests.

Policy Summary

PayerAvMed

PolicyPrior authorization for Tavalisse (fostamatinib)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with prescriber signature and supporting medical notes and platelet lab results within the last 28–30 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsInitial authorization duration

6 monthsReauthorization duration

<30Initial platelet threshold

50Reauth / symptomatic threshold

>=18Minimum age

Coverage Criteria for Tavalisse (fostamatinib)

Initial Therapy — Covered when ALL of the following are met for initial authorization

Covered when ALL of the following are met for initial authorization:

Initial Authorization Criteria: Requesting provider is a hematologist or has been in consultation with a hematologist; Member is >= 18 years of age; Diagnosis of chronic immune thrombocytopenia (ITP) refractory after >= 6 months of prior treatment; Documentation of platelet level within the last 30 days confirming < 30 x 10^9/L OR documentation of symptomatic bleeding or high risk for bleeding with platelet level within the last 30 days confirming < 50 x 10^9/L; Member has failed a first-line corticosteroid therapy (e.g., prednisone 0.5-2.0 mg/kg/day) and has documented failure of one other subsequent therapy (IVIG, rituximab, or splenectomy); Member has a documented trial and failure of a thrombopoietin (TPO) receptor agonist (e.g., eltrombopag, romiplostim, or avatrombopag), verified by chart note and/or pharmacy paid claims.see text

Initial authorization duration: 6 months; therapy will be discontinued after 12 weeks if platelet count does not increase to a sufficient level

Continuation/Reauthorization — Reauthorization covered when ALL of the following are met

Reauthorization covered when ALL of the following are met:

Policy Summary

PayerAvMed

PolicyPrior authorization for Tavalisse (fostamatinib)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with prescriber signature and supporting medical notes and platelet lab results within the last 28–30 days.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reauthorization Criteria: Member is not experiencing unacceptable toxicity from fostamatinib (examples include diarrhea, liver toxicity, hypertension, neutropenia); Clinical hematology laboratory tests and liver function tests have been monitored regularly and the most recent results are submitted (platelet count drawn within the previous 28 days); A platelet count of at least 50 x 10^9/L has been achieved and maintained at the lowest possible dose; Ongoing therapy is not combined with another thrombopoietin (TPO) receptor agonist.see text

Reauthorization duration: 6 months; therapy will be discontinued after 12 weeks if platelet count does not increase to a sufficient level

Medication may be dispensed from either the prescriber's office or a specialty pharmacy (Proprium Rx). Not all drugs are covered under every plan; if Tavalisse (fostamatinib) is non‑formulary for the member's plan, documentation of medical necessity is required to support coverage.

If therapy does not produce a clinically sufficient platelet response, treatment should be stopped. The policy specifies that therapy will be discontinued after 12 weeks if platelet count does not increase to a sufficient level (same discontinuation note appears in both initial and reauthorization criteria).

Relevant Clinical Thresholds and Coding

Platelet count thresholds — initial, symptomatic/high‑risk, and reauthorization

Initial authorization thresholdPlatelet count < 30 x 10^9/L documented within the last 30 days.

Symptomatic bleeding / high‑risk thresholdDocumentation of symptomatic bleeding or high bleeding risk and platelet count < 50 x 10^9/L within the last 30 days.

Reauthorization thresholdA platelet count of at least 50 x 10^9/L has been achieved and maintained (with labs submitted; most recent platelet drawn within previous 28 days).

Timing for platelet documentationPlatelet counts used for initial or symptomatic thresholds must be drawn within the last 30 days; for reauthorization the most recent platelet must be drawn within the previous 28 days.

Therapy discontinuation timingTherapy should be discontinued if platelet count does not increase to a sufficient level within 12 weeks.

Initial Authorization Criteria

Initial Authorization

Covered when ALL of the following are met for initial authorization:

Initial authorization duration: 6 months; therapy will be discontinued after 12 weeks if platelet count does not increase to a sufficient level

Reauthorization / Continuation Criteria

Reauthorization

Reauthorization covered when ALL of the following are met:

Reauthorization: Member is not experiencing unacceptable toxicity from fostamatinib (examples include diarrhea, liver toxicity, hypertension, neutropenia); Clinical hematology laboratory tests and liver function tests have been monitored regularly and the most recent results are submitted (platelet count drawn within the previous 28 days); A platelet count of at least 50 x 10^9/L has been achieved and maintained at the lowest possible dose; Ongoing therapy is not combined with another thrombopoietin (TPO) receptor agonist.see text

Reauthorization period: 6 months; therapy will be discontinued after 12 weeks if platelet count does not increase to a sufficient level

Prescriber and Office Staff Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — prescribing physician must sign and clearly print their name on the request (preprinted stamps not valid). All required clinical criteria must be met for approval. Incomplete, incorrect, or illegible information can delay processing or cause denial.

Prescribing physician signature required (no preprinted stamps).
Ensure provider phone and fax numbers are correct on form.

Step Therapy

Step-edit / Previous Therapy Verification

Step-edit/previous therapy verification will be enforced. Samples do not satisfy step-edit requirements; prior therapies will be verified via chart notes and/or paid pharmacy claims.

Samples do not meet step-edit/previous therapy requirements.
Prior therapy verification may use pharmacy paid claims or chart notes.

Documentation Required

Documentation attachments

Attach supporting documentation for each criterion checked. Required attachments include medical notes, diagnostics, and laboratory results (platelet counts). Platelet laboratory values must be recent: for initial requests, platelet levels within the last 30 days (confirming <30 x10^9/L or <50 x10^9/L when symptomatic/high bleeding risk); for reauthorization, platelet counts must be drawn within the previous 28 days.

Attach chart notes and diagnostics supporting each checked criterion.
Include platelet count lab results: initial requests = within 30 days; reauthorization = within 28 days.

Denial Risk

Form completion risk

Incomplete, incorrect, or illegible form fields (including missing medical notes or lab results) can delay the authorization process or result in denial. Ensure all required documentation is attached and legible before faxing the request.

Include medical notes and supporting lab results with the submission.
Double-check that all fields are complete and legible to avoid denial or processing delays.

Step Therapy Requirements

Step	Requirement
1	Documented trial and failure of a thrombopoietin (TPO) receptor agonist (e.g., eltrombopag, romiplostim, or avatrombopag) prior to approval (verified by chart note and/or pharmacy paid claims).

Site of Care and Dispensing

Billing Rule

Specify site of care: office or specialty pharmacy (may affect coverage)

Indicate whether the medication will be dispensed from the physician's office or a specialty pharmacy (Proprium Rx); the selected site of care may affect coverage and non-formulary status may require documentation of medical necessity.

Check physician's office or specialty pharmacy on the form
If non-formulary under the member's plan, submit documentation of medical necessity

Background

Chronic immune thrombocytopenia (ITP) is managed to raise platelet counts and reduce bleeding risk in adults whose disease persists despite prior treatments. Tavalisse (fostamatinib) is a spleen tyrosine kinase (SYK) inhibitor indicated for adults with refractory chronic ITP after prior therapies. Clinical use requires laboratory monitoring (including platelet counts and liver function tests) and documentation of prior treatment failures — for example, failure of corticosteroids and at least one other subsequent therapy, plus a documented trial and failure of a thrombopoietin (TPO) receptor agonist — before initiating or continuing therapy.

Definitions

Refractory Chronic Immune Thrombocytopenia (ITP) — definition & documentation

DefinitionChronic Immune Thrombocytopenia (ITP) refractory after previous treatment for ≥ 6 months — i.e., persistent disease despite at least 6 months of prior therapy.

Required documentation — diagnosis and durationDocumentation that ITP is chronic and refractory after ≥ 6 months of prior treatment must be submitted.

Required platelet dataSubmit platelet level documentation from within the last 30 days confirming the applicable low platelet threshold (<30 x 10^9/L or <50 x 10^9/L with symptomatic bleeding/high risk).

Prescriber specialty requirementRequesting provider must be a hematologist or have consulted with a hematologist (documented on the request).

Prior therapy requirementsDocumentation of failure of first‑line corticosteroid therapy and at least one other subsequent therapy (IVIG, rituximab, or splenectomy) is required to support refractory status.