Medicare AdvantagePrior AuthMedium impact
Tavalisse® (fostamatinib) (Revised)
Humana·Hematology, Pharmacy·Medicare Advantage
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Tavalisse (fostamatinib) prior authorization policy effective April 22, 2026. The policy maintains existing coverage criteria for chronic ITP requiring prior auth before dispensing: member must have relapsed/refractory ITP diagnosis, platelet count <50,000/microliter, and failed/intolerant response to Promacta or Nplate. Initial approvals are for 6 months with renewal based on therapeutic response (stable/increased platelets or decreased bleeding episodes). This is a routine policy revision with no substantive coverage changes.
Action Required
By April 22, 2026: Billing team must verify Tavalisse (fostamatinib) prescriptions in the EMR/pharmacy billing system trigger prior authorization requirements for Medicare Advantage members. Update or confirm PA submission protocols include verification of: (1) relapsed/refractory ITP diagnosis documentation, (2) platelet count <50,000/microliter from recent lab work, and (3) evidence of prior failed treatment/intolerance to Promacta (eltrombopag) or Nplate (romiplostim). For renewal requests, ensure documentation includes platelet count trending or bleeding episode frequency to demonstrate therapeutic response. Set PA approval duration to 6 months initial and plan year for renewals. Pharmacy staff should reference www.humana.com/PAL for updated claim codes. Failure to obtain PA before dispensing will result in claim denials for Medicare Advantage beneficiaries.