CurrentCignaPolicy N/A

Tavalisse (fostamatinib) prior authorization — chronic immune thrombocytopenia

Prior authorization policy governing coverage of Tavalisse (fostamatinib) for treatment of chronic immune thrombocytopenia (ITP) in adults under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyTavalisse (fostamatinib) prior authorization — chronic immune thrombocytopenia

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateApr 23, 2025

Key ActionObtain prior authorization and document platelet counts, prior therapies or splenectomy status, and hematologist involvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18min age (yrs)

<30,000platelet threshold

3 monthsinitial approval

1 yearcurrent-user approval

B-cell lymphoma/RAnot covered

Coverage Criteria for Tavalisse (fostamatinib)

Medical necessity criteria

Covered when ONE of the following FDA‑approved indication pathways is met for chronic immune thrombocytopenia (ITP):

FDA-Approved Indication: Chronic Immune Thrombocytopenia. Approve if the patient meets ONE of the following (A or B).

A) Initial Therapy (approve 3 months)

Patient is ≥ 18 years of age.
Platelet criteria
- a): Patient has a platelet count < 30 x 10^9/L (< 30,000/mcL).
- b)

Policy Summary

PayerCigna

PolicyTavalisse (fostamatinib) prior authorization — chronic immune thrombocytopenia

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateApr 23, 2025

Key ActionObtain prior authorization and document platelet counts, prior therapies or splenectomy status, and hematologist involvement.

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.

Indication	Policy coverage stance	Notes / rationale
B‑cell lymphomas (e.g., non‑Hodgkin's lymphoma, diffuse large B‑cell lymphoma [DLBCL])	Not Covered	Tavalisse has been investigated in patients with various B‑cell lymphomas, but many other therapies are available; use for these indications is considered not medically necessary.
Rheumatoid arthritis	Not Covered	Although studied in rheumatoid arthritis, other therapies are more well‑established and recommended in guidelines; use is considered not medically necessary.

Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization is required for Tavalisse. Approvals are provided for the durations specified: initial therapy approvals for 3 months; current users (continuation) approvals for 1 year. In cases where approval is authorized in months, 1 month = 30 days.

Initial therapy approval duration: 3 months (1 month = 30 days).
Current users (continuation) approval duration: 1 year.

Step Therapy

Prior Therapy Requirement

Prior therapy requirement. For initial therapy, the patient must have tried at least one other therapy unless they have undergone splenectomy. Examples of other therapies include systemic corticosteroids, intravenous immunoglobulin (IVIG), anti-D immunoglobulin, Promacta (eltrombopag), Nplate (romiplostim), Doptelet (avatrombopag), and rituximab.

Initial therapy: patient must have tried ≥ 1 other therapy OR have undergone splenectomy.
Examples of acceptable prior therapies: systemic corticosteroids; IVIG; anti-D immunoglobulin; Promacta (eltrombopag); Nplate (romiplostim); Doptelet (avatrombopag); rituximab.

Documentation Required

Prescriber and Documentation Requirements

Prescriber and clinical documentation. Approval requires Tavalisse to be prescribed by or in consultation with a physician who specializes in the condition being treated (e.g., a hematologist). Clinical documentation must support the applicable criteria for the requested indication, including age, platelet counts, bleeding-risk assessment, prior therapies or splenectomy status, and—for continuation—evidence of beneficial clinical response and ongoing bleeding risk.

Prescriber requirement: prescribed by or in consultation with a specialist (hematologist) for the condition being treated.
Documentation to include: patient age, platelet counts, evidence of prior therapy or splenectomy, bleeding risk assessment, and for continuation therapy, prescriber attestation of beneficial clinical response and continued bleeding risk.

Denial Risk

Billing and Coding Denial Risk

Billing / coding denial risk. Claims submitted without covered diagnosis or procedure codes consistent with the applicable coverage policy may be denied as not covered. Use the most appropriate codes as of the date of submission and include supporting documentation with the prior authorization and claims.

Claims lacking covered diagnosis/procedure codes under the applicable coverage policy may be denied.
Ensure coding aligns with the benefit plan and include supporting clinical documentation with submissions.

Definitions

Chronic Immune Thrombocytopenia (ITP) — definition and indication context for Tavalisse

Definition of conditionChronic Immune Thrombocytopenia (ITP): an autoimmune condition causing thrombocytopenia; Tavalisse is indicated for adults with chronic ITP who had an insufficient response to prior treatment.

Eligible populationAdults ≥ 18 years of age (safety and efficacy not established in pediatric patients; not recommended <18 years due to bone adverse events in nonclinical studies).

Indication context for TavalisseTavalisse (fostamatinib) is indicated for treatment of thrombocytopenia in adults with chronic ITP who had an insufficient response to a previous treatment — used when patient meets FDA‑approved criteria (initial therapy or currently receiving).

Treatment continuation noteDiscontinue if platelet count does not increase to a sufficient level to control bleeding after 12 weeks of treatment.

OpenPayer

Tavalisse (fostamatinib) prior authorization — chronic immune thrombocytopenia

Coverage Criteria for Tavalisse (fostamatinib)

Investigational and Non‑Covered Regimens

Clinical Thresholds and Coding-relevant Criteria

Provider Requirements and Authorization Process

Background on Tavalisse (fostamatinib)

Definitions