By Counterforce Health Team in Cabometyx (cabozantinib) —

Cabometyx (Cabozantinib) Approval with UnitedHealthcare in Virginia: Your Complete Coverage Guide

Quick Answer: Getting Cabometyx Covered by UnitedHealthcare in Virginia

Yes, Cabometyx (cabozantinib) tablets require prior authorization from UnitedHealthcare/OptumRx for all FDA-approved indications in Virginia. The fastest path: Have your oncologist submit a complete PA request through the UnitedHealthcare Provider Portal with diagnosis, staging, prior therapies, and medical necessity documentation. Initial approval typically takes 5-7 business days. If denied, Virginia's external review process through the State Corporation Commission provides strong appeal rights with an 81.7% overturn rate for specialty drug denials.

First step today: Call UnitedHealthcare member services at 1-800-711-4555 to verify your specialty pharmacy benefits and confirm OptumRx is your preferred specialty pharmacy.

Table of Contents

  1. Is Cabometyx Covered by UnitedHealthcare?
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Clinical Criteria and Requirements
  5. Understanding Your Costs
  6. When Coverage is Denied
  7. Renewal and Reauthorization
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. Virginia-Specific Appeal Rights

Is Cabometyx Covered by UnitedHealthcare?

Coverage Status: Cabometyx (cabozantinib) tablets are covered by UnitedHealthcare plans in Virginia, but require prior authorization for all FDA-approved indications including renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), and differentiated thyroid cancer.

Important: Cabometyx tablets are NOT interchangeable with cabozantinib capsules (Cometriq). UnitedHealthcare requires the correct formulation and NDC codes—substitution attempts will result in automatic denial.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications UHC Provider Portal UHC PA Requirements
Formulary Tier Specialty tier (Tier 4/5) Member benefits summary Plan documents
Step Therapy May apply for HCC Clinical documentation needed OptumRx Criteria
Specialty Pharmacy OptumRx preferred Dispensing restriction UHC Specialty Network
Appeals Deadline 180 days from denial Internal appeal first UHC Administrative Guide

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Benefits (Patient/Clinic Staff)
    • Call UnitedHealthcare: 1-800-711-4555
    • Confirm specialty pharmacy coverage through OptumRx
    • Timeline: 5-10 minutes
  2. Gather Clinical Documentation (Prescriber)
    • Confirmed diagnosis with staging/imaging
    • Prior therapy history and outcomes
    • Medical necessity justification
    • Timeline: 1-2 business days
  3. Submit PA Request (Prescriber)
  4. Initial Review (UnitedHealthcare)
    • Standard review: 5-7 business days
    • Expedited review: 72 hours (if urgent)
    • Timeline: Per CMS requirements
  5. Approval or Denial Notice (UnitedHealthcare)
    • Written determination with rationale
    • If approved: 12-month authorization typical
    • Timeline: Within review period

Who Submits the Prior Authorization?

Your prescribing oncologist or their staff submits the PA request. Patients cannot submit directly, but you can:

  • Request status updates from your clinic
  • Call UnitedHealthcare to verify receipt
  • Ensure all documentation is complete

Timeline and Urgency

Standard Timeline

  • PA Review: 5-7 business days from complete submission
  • Specialty Pharmacy Processing: 2-3 business days after approval
  • Total Time to First Dose: 7-10 business days

Expedited Review

When available: Life-threatening conditions or serious health risks Timeline: 72 hours for determination How to request: Prescriber must certify medical urgency in PA request

Note: Cancer treatment often qualifies for expedited review. Your oncologist should request this if treatment delays could compromise outcomes.

Clinical Criteria and Requirements

For Renal Cell Carcinoma (RCC)

  • Confirmed diagnosis of Stage IV or relapsed RCC
  • Appropriate line of therapy per NCCN guidelines
  • Documentation of performance status
  • Prior imaging with RECIST measurements (if applicable)

For Hepatocellular Carcinoma (HCC)

  • Confirmed HCC diagnosis
  • Step therapy requirement: Trial, contraindication, or intolerance to sorafenib (Nexavar)
  • Child-Pugh Class A liver function preferred
  • Prior systemic therapy documentation

Clinician Corner: Medical Necessity Letter Checklist

Your oncologist should include:

  • Problem: Specific cancer diagnosis with staging
  • Prior treatments: Detailed history with dates and outcomes
  • Clinical rationale: Why Cabometyx is appropriate now
  • Guideline support: Reference to NCCN Guidelines or FDA labeling
  • Dosing plan: 60mg daily or combination protocol
  • Monitoring plan: Response assessment timeline

Understanding Your Costs

Insurance Coverage

  • Specialty tier copay: Typically 25-40% coinsurance after deductible
  • Annual out-of-pocket maximum: Check your specific plan
  • Prior to deductible: You may pay full cost until deductible is met

Cost Assistance Options

  • Manufacturer support: Exelixis offers patient assistance programs
  • Copay cards: Available for commercial insurance (not Medicare/Medicaid)
  • Foundation grants: Organizations like CancerCare provide financial assistance
  • Virginia resources: Contact the Virginia Poverty Law Center for additional support options
Tip: Apply for manufacturer assistance before your first fill. OptumRx specialty pharmacists can help coordinate these programs.

When Coverage is Denied

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
Wrong formulation Confirm Cabometyx tablets, not capsules Correct NDC in prescription
Missing step therapy Document sorafenib trial/failure/contraindication Clinical notes with dates and outcomes
Insufficient medical necessity Strengthen clinical rationale Updated letter with guideline references
Incomplete documentation Submit all required forms Staging, labs, prior therapy records

Appeals Process for UnitedHealthcare

Level 1: Internal Appeal

  • Deadline: 180 days from denial notice
  • How to file: UnitedHealthcare Provider Portal or written request
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required: Additional clinical documentation

Level 2: External Review (Virginia)

  • When: After internal appeal exhaustion
  • Deadline: 120 days from final internal denial
  • Process: Virginia State Corporation Commission Bureau of Insurance
  • Success rate: 81.7% overturn rate for specialty drugs

Renewal and Reauthorization

When to Reauthorize

  • Initial approval: Typically 12 months
  • Renewal timing: Submit 30-60 days before expiration
  • Required documentation: Response assessment, continued medical necessity

What Changes Trigger New PA?

  • Dose adjustments outside approved range
  • New indication or off-label use
  • Change in cancer staging or treatment plan
  • Insurance plan changes

Specialty Pharmacy Requirements

Why Specialty Pharmacy?

Cabometyx requires specialized handling, storage, and patient monitoring that only certified specialty pharmacies can provide.

OptumRx Specialty Pharmacy (Preferred)

  • Phone: 1-888-463-6332
  • Services: Prior authorization coordination, copay assistance, clinical support
  • Shipping: Temperature-controlled, signature required
  • Refill reminders: Automated system to prevent gaps

Alternative Network Pharmacies

  • Accredo Specialty Pharmacy
  • AllianceRx Walgreens Prime
  • CVS Specialty (verify network status)
Important: Using non-network specialty pharmacies may result in higher costs or coverage denial.

Troubleshooting Common Issues

Portal Problems

Issue: Provider portal down or not accepting submissions Solution: Call UnitedHealthcare Provider Services at 1-800-711-4555 for alternative submission methods

Missing Forms

Issue: PA form not found or outdated Solution: Use current UHC PA notification forms (verify current version)

Delayed Response

Issue: No determination after standard timeline Solution: Request expedited review if clinically appropriate, or file complaint with Virginia SCC

Virginia-Specific Appeal Rights

External Review Process

Virginia provides robust external review rights through the State Corporation Commission Bureau of Insurance.

Key Benefits:

  • Independent medical review by qualified oncologists
  • 81.7% success rate for overturning denials
  • Expedited process available for urgent cases
  • No cost to patients

How to File External Review

  1. Complete internal appeals with UnitedHealthcare first
  2. File within 120 days of final internal denial
  3. Use official forms: Virginia External Review Request
  4. Submit supporting evidence within 5 business days of acceptance

Virginia Consumer Resources

  • SCC Bureau of Insurance: 1-877-310-6560
  • Managed Care Ombudsman: Same number, specialized HMO assistance
  • Virginia Poverty Law Center: Legal assistance for coverage appeals

Frequently Asked Questions

Q: How long does UnitedHealthcare PA take in Virginia? A: Standard review is 5-7 business days. Expedited review for urgent cases is completed within 72 hours.

Q: What if Cabometyx is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Your oncologist should emphasize clinical superiority over formulary alternatives.

Q: Can I request an expedited appeal? A: Yes, if your oncologist certifies that delays could seriously compromise your health. Both internal and external reviews offer expedited timelines.

Q: Does step therapy apply if I failed treatments outside Virginia? A: Yes, prior therapy documentation from any location counts toward step therapy requirements. Ensure all records are submitted.

Q: What happens if my appeal is denied? A: You can pursue external review through Virginia's SCC, which has binding authority over UnitedHealthcare's coverage decisions.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients, clinicians, and specialty pharmacies. Our platform analyzes denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals that align with payer-specific requirements. For complex cases like Cabometyx coverage, we help identify denial patterns and craft compelling rebuttals that improve approval rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage policies and requirements may vary by specific plan and change over time. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For personalized assistance with appeals and prior authorization, consider consulting with Counterforce Health or other qualified advocacy services.

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