By Counterforce Health Team in Cabometyx (cabozantinib) —

Get Cabometyx (Cabozantinib) Covered by UnitedHealthcare in New Jersey: Complete PA Guide, Appeals, and IHCAP Process

Answer Box: Getting Cabometyx Covered by UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization (PA) for Cabometyx (cabozantinib) through OptumRx for all cancer indications. Fastest path: Have your oncologist submit PA via the UnitedHealthcare Provider Portal with diagnosis confirmation, prior therapy details, and RECIST imaging. If denied, New Jersey residents can appeal through UnitedHealthcare's internal process, then file for external review through New Jersey's IHCAP program administered by Maximus Federal Services. Start today: Verify your plan uses OptumRx and ask your oncologist to begin the PA process immediately.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Medical Necessity Criteria
  5. Costs and Financial Assistance
  6. Denials and Appeals
  7. Renewal Requirements
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. FAQ

Coverage Basics

Is Cabometyx Covered by UnitedHealthcare?

Yes, but with restrictions. UnitedHealthcare covers Cabometyx tablets (not capsules) for FDA-approved indications including advanced renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), and differentiated thyroid cancer (DTC). Coverage requires prior authorization through OptumRx for all commercial, Medicare Advantage, and Medicaid plans in New Jersey.

Which UnitedHealthcare Plans Are Affected?

  • Commercial employer plans using OptumRx pharmacy benefits
  • UnitedHealthcare Community Plan (New Jersey Medicaid/CHIP)
  • Medicare Advantage plans with OptumRx
  • Health Insurance Marketplace plans in New Jersey

Important: Self-funded employer plans may have different criteria. Check your member ID card to confirm OptumRx is your pharmacy benefit manager.

Prior Authorization Process

Who Submits the PA?

Your oncologist or their staff must submit the prior authorization request. Patients cannot submit PAs directly, but you can help gather required documentation.

How to Submit

  1. Online: UnitedHealthcare Provider Portal (fastest method)
  2. Phone: 866-889-8054 for commercial pharmacy PA
  3. Fax: Use plan-specific fax number from denial letter or provider portal

Required Documentation

Based on UnitedHealthcare's Cabometyx clinical policy, include:

  • Diagnosis confirmation with ICD-10 code
  • Cancer staging and pathology reports
  • Prior systemic therapies and outcomes (required for HCC, endometrial cancer)
  • RECIST 1.1 imaging showing disease progression
  • Performance status assessment
  • Planned dosing (typically 60mg daily for monotherapy)
Clinician Corner: Medical necessity letters should explicitly reference NCCN guidelines and FDA labeling. For subsequent-line therapy requirements (HCC, endometrial cancer), document specific prior treatments and progression dates with imaging reports.

Timeline and Urgency

Standard Processing Times

  • Initial PA review: 10 business days for commercial plans
  • Urgent/expedited: 72 hours when delay would seriously jeopardize health
  • Medicare Advantage: 72 hours for urgent, 14 days for standard

When to Request Expedited Review

Request expedited processing if:

  • Patient has rapidly progressing cancer
  • Delay would cause serious harm to health
  • Current therapy has failed and immediate alternative needed

Note: Include clinical justification for urgency in your PA request.

Medical Necessity Criteria

FDA-Approved Indications Covered

Cancer Type Line of Therapy Additional Requirements
Renal Cell Carcinoma First-line (combination) or subsequent Advanced/metastatic disease
Hepatocellular Carcinoma Subsequent-line only Prior systemic therapy required
Differentiated Thyroid Cancer After VEGFR therapy RAI-refractory, age ≥12 years
Endometrial Carcinoma Second-line or later Prior therapy documented
NCCN-Supported Uses Per guidelines Category 1/2A/2B recommendation

Common Step Therapy Requirements

UnitedHealthcare uses "line of therapy" requirements rather than specific drug-to-drug step therapy:

  • HCC: Must be subsequent-line (after sorafenib, lenvatinib, or other systemic therapy)
  • Endometrial cancer: Must be second-line or later
  • RCC: First-line combinations allowed; monotherapy typically subsequent-line

Costs and Financial Assistance

Typical Cost-Sharing

Cabometyx is placed on Specialty Tier 4-5 with:

  • Commercial plans: 25-40% coinsurance after deductible
  • Medicare: 25-33% coinsurance in coverage gap
  • Medicaid: Minimal copay after PA approval

Financial Assistance Options

  • Exelixis Patient Support: Copay assistance and free drug programs
  • New Jersey pharmaceutical assistance programs for eligible residents
  • Foundation grants through organizations like CancerCare and Patient Access Network

Denials and Appeals

Common Denial Reasons and Fixes

Denial Reason How to Fix Required Documentation
Wrong formulation Clarify tablets vs capsules Prescription for Cabometyx tablets specifically
Not subsequent-line Document prior therapies Treatment history with progression dates
Diagnosis not supported Provide pathology/staging Biopsy reports, imaging, ICD-10 codes
Missing imaging Submit RECIST documentation CT/MRI with measurable disease progression

UnitedHealthcare Appeals Process

Internal Appeals (Required First):

  1. Stage 1: Submit within 60 days of denial
  2. Stage 2: If Stage 1 denied, appeal within 60 days
  3. Expedited: 72 hours for urgent cases

Submit appeals via:

  • UnitedHealthcare member portal
  • Written appeal to address on denial letter
  • Fax number provided in denial notice

New Jersey External Review (IHCAP)

After exhausting UnitedHealthcare's internal appeals, New Jersey residents can file for independent external review through the Independent Health Care Appeals Program (IHCAP).

Key Details:

  • Administrator: Maximus Federal Services
  • Filing deadline: 4 months from final internal denial
  • Timeline: 45 days for standard review, 48 hours for expedited
  • Cost: Free to patients
  • Portal: njihcap.maximus.com

Required for IHCAP:

  • Completed internal appeals with UnitedHealthcare
  • Denial letters from all internal appeal levels
  • Medical records supporting medical necessity
  • Patient consent form (providers can file on behalf)
From Our Advocates: In our experience helping patients navigate oncology appeals in New Jersey, having your oncologist submit a detailed peer-to-peer review request before formal appeals can sometimes resolve denials faster. The key is addressing the specific denial reason with updated clinical documentation rather than resubmitting the same information.

Renewal Requirements

Reauthorization Timeline

Cabometyx approvals are typically granted for 12 months and require reauthorization before expiration.

What's Needed for Renewal

According to UnitedHealthcare's policy:

  • No evidence of disease progression on current therapy
  • Updated imaging showing stable disease or response
  • Confirmation of ongoing tolerability
  • Performance status assessment

Tip: Start the reauthorization process 30-45 days before expiration to avoid treatment interruptions.

Specialty Pharmacy Requirements

Where Cabometyx Must Be Filled

UnitedHealthcare requires Cabometyx to be dispensed through OptumRx specialty pharmacy network. Retail pharmacies typically cannot fill specialty oncology medications under UnitedHealthcare plans.

Specialty Pharmacy Process

  1. After PA approval: Prescription automatically transferred to designated specialty pharmacy
  2. Patient contact: Specialty pharmacy will call to coordinate delivery
  3. Delivery: Typically overnight shipping with signature required
  4. Refills: Automatic coordination with prescriber for refills

Note: If your prescription was sent to a retail pharmacy, ask them to transfer it to the OptumRx specialty network.

Troubleshooting Common Issues

Portal Access Problems

  • Provider portal down: Call 866-889-8054 for commercial pharmacy PA
  • Missing forms: Download current forms from UnitedHealthcare provider resources
  • Status check: Use provider portal or call customer service number on member ID card

Documentation Issues

  • Missing prior therapy records: Request records from previous oncologists
  • Imaging not RECIST-compliant: Ask radiologist to provide measurements per RECIST 1.1 criteria
  • Diagnosis coding errors: Verify ICD-10 codes match pathology reports

Communication Gaps

  • Between patient and clinic: Request copies of all PA submissions
  • Between clinic and specialty pharmacy: Confirm prescription transfer
  • Between insurance and providers: Ask for peer-to-peer review if initial PA denied

Frequently Asked Questions

How long does UnitedHealthcare PA take in New Jersey?

Standard PA decisions are made within 10 business days for commercial plans and 14 days for Medicare Advantage. Expedited reviews are completed within 72 hours when urgent medical need is documented.

What if Cabometyx is non-formulary on my plan?

Even if non-formulary, Cabometyx can be covered through medical necessity exceptions. Your oncologist should submit a PA with clinical justification referencing FDA labeling and NCCN guidelines.

Can I request an expedited appeal?

Yes, if delay would seriously jeopardize your health. Include clinical documentation supporting the urgent need, such as rapidly progressing disease or failure of current therapy.

Does step therapy apply if I've failed therapies outside New Jersey?

Yes, prior therapies from any location count toward step therapy requirements. Provide documentation of treatments tried and outcomes, including progression dates and imaging.

What happens if IHCAP overturns UnitedHealthcare's denial?

UnitedHealthcare must comply with IHCAP decisions and provide coverage without delay. They must also report implementation to Maximus, the patient, provider, and New Jersey Department of Banking and Insurance.

How do I get help with the appeals process?

Contact the New Jersey Department of Banking and Insurance consumer hotline at 1-800-446-7467 or the IHCAP-specific line at 1-888-393-1062.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, payer-specific appeal letters. Our platform identifies denial reasons and drafts targeted rebuttals aligned to each plan's own policies, pulling the right clinical evidence and operational details that payers expect to see.

For complex Cabometyx appeals in New Jersey, Counterforce Health's platform can help generate targeted appeal letters that address UnitedHealthcare's specific clinical criteria while incorporating New Jersey's external review protections.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For the most up-to-date information on New Jersey insurance regulations and appeal rights, visit the New Jersey Department of Banking and Insurance website.

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