By Counterforce Health Team in Cabometyx (cabozantinib) —

Get Cabometyx (Cabozantinib) Covered by Aetna in Michigan: Complete PA Guide and Appeals Process

Answer Box: Getting Cabometyx Covered by Aetna in Michigan

Cabometyx (cabozantinib) requires prior authorization from Aetna CVS Health for all FDA-approved cancer indications in Michigan. The fastest path to approval: (1) Submit complete PA documentation through your oncologist including prior therapy failures and recent imaging, (2) Use Aetna's provider portal or CVS Specialty for submission, (3) If denied, file internal appeal within 180 days, then external review with Michigan DIFS within 127 days. First step today: Call your oncologist to verify they have your complete treatment history and recent scans ready for PA submission.

Table of Contents

Coverage Basics

Is Cabometyx Covered by Aetna?

Yes, but with important caveats. Cabometyx is excluded from Aetna's 2024 Advanced Control formulary, meaning most commercial and exchange plans require a formulary exception rather than standard prior authorization. This significantly impacts approval timelines and documentation requirements.

Coverage varies by plan type:

  • Commercial/Exchange plans: Formulary exception required (longer process)
  • Medicare plans: Standard prior authorization pathway
  • Medicaid plans: Coverage varies by state Medicaid formulary

Which Cancer Types Are Covered?

Aetna covers Cabometyx for three FDA-approved indications:

Cancer Type ICD-10 Codes Special Requirements
Renal cell carcinoma C64.9, C64.1, C64.2 Standard PA pathway
Hepatocellular carcinoma C22.0 Must document prior sorafenib failure
Differentiated thyroid cancer C73 Must show radioactive iodine-refractory status
Critical Note: Cabometyx tablets and Cometriq capsules (both containing cabozantinib) are not interchangeable. Ensure your prescription specifies Cabometyx tablets with correct NDC codes.

Prior Authorization Process

Required Documentation

Submit complete documentation through Aetna's provider portal at least two weeks before planned therapy. Incomplete submissions are the primary cause of delays and denials.

Essential documents include:

  • Medical necessity letter addressing Aetna's specific criteria
  • Pathology reports confirming cancer diagnosis and type
  • Prior therapy documentation with specific drugs, dates, durations, and outcomes
  • Recent imaging (past 6 months) with RECIST criteria measurements
  • Lab results showing liver and kidney function
  • Current medication list for drug interaction review
  • Cancer staging and current disease status
  • Prescriber credentials confirming oncology certification

Step-by-Step Submission Process

  1. Gather Documentation (Patient + Clinic)
    • Insurance card with member ID
    • Complete treatment history from all providers
    • Recent scans and lab results
    • Timeline: 1-2 days
  2. Complete PA Form (Oncologist)
    • Use Aetna's oncology prior authorization form
    • Include all required clinical documentation
    • Submit via: Availity portal or EMR integration
    • Timeline: 2-3 business days
  3. CVS Specialty Coordination (Pharmacy)
    • Verify in-network specialty pharmacy status
    • Coordinate prescription transfer if needed
    • Timeline: 1-2 business days
  4. Aetna Review (Insurance)
    • Medical review by oncology-trained clinician
    • Possible peer-to-peer review request
    • Timeline: See timing section below

Timing and Deadlines

Approval Timelines

Request Type Commercial Plans Medicare Plans
Standard PA 30-45 days 72 hours
Formulary Exception 45-60 days 7 days
Expedited/Urgent 72 hours 72 hours
Peer-to-Peer Review 24-48 hours 24-48 hours
Tip: Request expedited review if treatment delay would jeopardize your health. Your oncologist must provide supporting documentation.

Michigan-Specific Appeal Deadlines

  • Internal Appeal: 180 days from denial notice
  • External Review with DIFS: 127 days from Aetna's final internal denial
  • Expedited External Review: 72 hours (requires physician letter)

Step Therapy Requirements

Aetna enforces step therapy requiring documented evidence of previous treatment failures. You must provide records showing why formulary alternatives were ineffective or caused adverse effects.

Common Step Therapy Requirements by Cancer Type

Renal Cell Carcinoma:

  • First-line: Sunitinib, pazopanib, or other VEGF inhibitors
  • Document specific side effects or disease progression
  • Include imaging showing progression dates

Hepatocellular Carcinoma:

  • Required: Prior sorafenib treatment
  • Document duration, dosing, and reason for discontinuation
  • Include liver function monitoring results

Thyroid Cancer:

  • Required: Prior radioactive iodine therapy
  • Must show RAI-refractory status
  • Document VEGFR therapy failure if applicable

Costs and Financial Support

Insurance Coverage Costs

Specialty tier medications typically carry 25-40% coinsurance after meeting your deductible. Exact costs vary by plan - check your Summary of Benefits or call the member services number on your insurance card.

Exelixis Access Services (EASE) Program

Co-Pay Assistance:

  • Benefit: $0 per month for eligible patients
  • Eligibility: Commercially insured (not government-funded plans)
  • Contact: 1-855-690-0340
  • Application: Complete $0 Co-Pay Card enrollment

Patient Assistance Program:

  • Benefit: Free Cabometyx for qualifying patients
  • Eligibility: Uninsured/underinsured unable to afford medication
  • Application: Fax completed form to 1-855-915-3005

30-Day Free Trial:

  • Available for new patients if insurance approval delayed >5 days
  • Coordinate through your healthcare provider and EASE
Michigan Medicaid Note: Plans like CareSource MI offer $0 copays for covered drugs, but prior authorization and step therapy may still apply.

Denials and Appeals

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Wrong formulation Specify Cabometyx tablets vs. Cometriq capsules Prescription with correct NDC codes
Off-label use Provide FDA indication support FDA label, clinical guidelines
Missing imaging Submit recent scans with RECIST measurements Radiology reports <6 months old
Drug interactions Address contraindications Medication reconciliation, safety plan
Step therapy not met Document prior failures Treatment records with dates, outcomes

Michigan Appeals Process

Internal Appeal (Required First Step):

  1. File within 180 days of denial
  2. Submit via Aetna member portal or written request
  3. Include all supporting clinical documentation
  4. Timeline: 30 days for standard, 72 hours for expedited

External Review with Michigan DIFS:

  1. File within 127 days of Aetna's final denial
  2. Use DIFS online form or paper submission
  3. Contact: 877-999-6442 for forms and guidance
  4. Timeline: Up to 60 days (72 hours for expedited)
  5. Decision: Binding on Aetna if approved
From our advocates: We've seen cases where an initial Cabometyx denial was overturned within 48 hours simply by including detailed records of three failed previous treatments with specific dates and imaging results. Complete documentation makes the difference.

Specialty Pharmacy Requirements

CVS Specialty Network

Most Aetna plans require Cabometyx to be dispensed through CVS Specialty or other contracted specialty pharmacies. This is not optional - using a non-network pharmacy may result in no coverage.

Key steps:

  • Verify your plan's specialty pharmacy network
  • Coordinate prescription transfer through your oncologist
  • Ensure PA approval before specialty pharmacy fills prescription
  • Set up delivery and adherence monitoring

Prescription Transfer Process

  1. Your oncologist sends prescription to designated specialty pharmacy
  2. Specialty pharmacy contacts you to verify insurance and shipping
  3. PA approval must be in place before first fill
  4. Ongoing refills require periodic reauthorization

Common Issues and Solutions

Portal and System Issues

  • Availity portal down: Call Aetna provider services at 1-800-282-2872
  • Missing PA forms: Download from Aetna provider website or request via phone
  • Prescription stuck in system: Contact CVS Specialty directly

Documentation Problems

  • Missing prior therapy records: Request from all previous oncologists
  • Incomplete imaging: Ensure reports include RECIST measurements
  • Wrong diagnosis codes: Verify ICD-10 codes match your specific cancer type

Peer-to-Peer Review

If Aetna requests a peer-to-peer review, this occurs before formal appeal. Your oncologist will discuss the case directly with an Aetna medical reviewer. This is often the fastest path to approval for complex cases.

FAQ

How long does Aetna prior authorization take for Cabometyx in Michigan? Standard PA takes 30-45 days for commercial plans, 72 hours for Medicare. Formulary exceptions may take 45-60 days. Request expedited review if medically urgent.

What if Cabometyx is non-formulary on my plan? Submit a formulary exception request with comprehensive clinical documentation. This process takes longer than standard PA but is often successful with proper justification.

Can I request an expedited appeal in Michigan? Yes, if treatment delay would jeopardize your health. Your physician must provide a supporting letter. Expedited appeals are decided within 72 hours.

Does step therapy apply if I failed treatments outside Michigan? Yes, treatment history from any location counts toward step therapy requirements. Gather records from all previous providers.

What's the difference between Cabometyx tablets and cabozantinib capsules? They are not interchangeable due to different pharmacokinetics. Cabometyx (tablets) and Cometriq (capsules) have different dosing and administration requirements.

How do I check my Cabometyx PA status? Log into your Aetna member portal, call member services, or have your provider check through Availity. Keep your member ID and reference number handy.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned to each plan's own rules, pulling the right clinical evidence and meeting all procedural requirements.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult your healthcare provider and insurance plan for specific coverage decisions. For additional help with insurance appeals in Michigan, contact the Michigan Department of Insurance and Financial Services at 877-999-6442.

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