CurrentColorado Rocky Mountain Health PlansPolicy N/A

Tavalisse (fostamatinib) prior authorization

Prior authorization and reauthorization criteria for Tavalisse (fostamatinib) for treatment of chronic immune thrombocytopenia (ITP) in adults; applies to UnitedHealthcare pharmacy clinical programs and affected members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTavalisse (fostamatinib) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionProvide documentation of chronic ITP diagnosis and prior inadequate response to other treatments when requesting initial authorization; document positive clinical response for reauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

adult ITPindication covered

12 monthsauthorization duration

prior treatment requiredinitial therapy requirement

P&T 2018-2026program review history

Coverage Criteria for Tavalisse (fostamatinib)

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.

inv-01: Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met:

Initial Authorization for Tavalisse: (1) Diagnosis of chronic immune thrombocytopenia (ITP)

Initial Authorization for Tavalisse: (2) Patient has had an insufficient response to a previous treatment (e.g., corticosteroids, immunoglobulins, thrombopoietin receptor agonists, splenectomy)

inv-02: Continuation Therapy / Reauthorization — Reauthorization covered when the following is met

Reauthorization covered when the following is met:

Reauthorization for Tavalisse: Documentation of positive clinical response to Tavalisse therapy

Authorization will be issued for 12 months; state mandates and member benefit plan coverage may affect criteria

In addition to the clinical coverage requirements above, plan-specific rules and state or federal mandates may apply. UnitedHealthcare programs may use automated approval or reauthorization processes that rely on prior claim or medication history and diagnosis coding rather than full clinical documentation. Also note that supply limits may be in place and may affect approved quantities.

Provider Requirements, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization required. Tavalisse (fostamatinib) initial approvals require documentation of a diagnosis of chronic immune thrombocytopenia (ITP) and evidence that the patient has had an inadequate response to prior therapies.

Initial authorization: Document diagnosis of chronic ITP.
Initial authorization: Document prior insufficient response to therapies such as corticosteroids, IVIG, thrombopoietin receptor agonists (TPO-RAs), or splenectomy.

Documentation Required

Reauthorization and Duration

Reauthorization requests must include documentation of a positive clinical response to therapy. Authorizations are issued for up to 12 months.

Reauthorization: Document sustained clinical benefit (e.g., increased platelet counts, reduced bleeding events, or other clinician-documented improvement).
Duration: Authorizations granted for 12 months; state mandates and member-specific benefit plan terms may affect coverage.

Note

Prior Treatment Expectation

Prior treatment expectation: initial approvals presume prior inadequate response to standard ITP therapies before initiating Tavalisse.

Expected prior therapies: corticosteroids, intravenous immunoglobulin (IVIG), thrombopoietin receptor agonists (TPO-RAs), or prior splenectomy when applicable.
If prior therapies were not used, document clinical rationale why Tavalisse is appropriate as initial therapy.

Documentation Required

Required Documentation

Required documentation: include diagnosis, past treatment history with responses, and objective evidence of benefit on Tavalisse for both initial and renewal requests.

Initial requests: clinical notes confirming chronic ITP diagnosis and records showing insufficient response to prior treatments.
Reauthorization requests: clinical progress notes, recent platelet counts, and documentation of clinical improvement attributable to Tavalisse.

Denial Risk

Triggers for Denial

Denial triggers: missing or incomplete documentation of chronic ITP diagnosis or lack of documented inadequate response to prior therapies may result in denial of coverage.

No documentation confirming chronic ITP (duration, diagnostic criteria).
No evidence of prior inadequate response to corticosteroids, IVIG, TPO-RAs, or splenectomy without a documented clinical rationale.
Reauthorization without demonstration of clinical benefit (e.g., absent platelet count improvement or clinical notes showing response).

Required prior therapy (step)	Notes / examples	Coverage label
Step 1: Prior inadequate response to other ITP treatments	Examples include corticosteroids, immunoglobulins, thrombopoietin receptor agonists, or splenectomy (insufficient response)	Covered with criteria

Key Definitions

Chronic immune thrombocytopenia (ITP) — definition and scope (adults)

DefinitionChronic immune thrombocytopenia (ITP) is an immune-mediated condition characterized by low platelet counts; policy applies to adult patients with chronic ITP, consistent with the Tavalisse indication.

Covered indicationTreatment of thrombocytopenia in adult patients with chronic ITP who have had an insufficient response to a previous treatment.

Prior treatment expectationInitial authorization requires documentation of insufficient response to prior therapies (examples: corticosteroids, immunoglobulins, thrombopoietin receptor agonists, or splenectomy).

Reauthorization requirementReauthorization requires documentation of a positive clinical response to Tavalisse; authorizations are issued for 12 months.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTavalisse (fostamatinib) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2026

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Tavalisse (fostamatinib) prior authorization

Coverage Criteria for Tavalisse (fostamatinib)

Initial Authorization Requirements

Reauthorization and Continuation Rules

Provider Requirements, Documentation, and Denial Triggers

Step Therapy / Prior Treatment Expectations

Quantity Limits and Supply Constraints

Background on Tavalisse and Indication

Key Definitions