By Counterforce Health Team in Cometriq (cabozantinib) —

Get Cometriq (Cabozantinib) Covered by UnitedHealthcare in Pennsylvania: Complete Forms, Appeals & Contact Guide

Answer Box: Getting Cometriq Covered by UnitedHealthcare in Pennsylvania

Fastest path to approval: Submit prior authorization through the UnitedHealthcare Provider Portal with oncologist documentation of progressive, metastatic medullary thyroid cancer. Required: ICD-10 diagnosis codes, pathology reports, and evidence of disease progression. Timeline: 72 hours for standard PA decisions. If denied: Use Pennsylvania's new external review program—50% success rate in 2024. Start today: Verify your plan covers specialty drugs and gather medical records showing medullary thyroid cancer diagnosis.

Table of Contents

  1. Verify Your Plan & Coverage
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Upload Instructions
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Transfer Process
  6. Support Lines & Who to Call
  7. Pennsylvania Appeals & External Review
  8. Common Denial Reasons & Solutions
  9. Update Schedule & Resource Maintenance

Verify Your Plan & Coverage

Before starting the approval process, confirm your UnitedHealthcare plan covers specialty medications. Cometriq requires prior authorization across all UnitedHealthcare plans in Pennsylvania.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans UHC PA Requirements UHC Policy
Formulary Status Specialty tier (high cost-sharing) Member portal or call member services Plan documents
Specialty Pharmacy Must use OptumRx or approved network UHC Specialty Drugs List UHC Policy
Diagnosis Required Progressive, metastatic medullary thyroid cancer FDA labeling and UHC criteria UHC PA Notification
Tip: Call the number on your insurance card to verify your specific plan's specialty drug benefits before beginning the PA process.

Prior Authorization Forms & Requirements

Step-by-Step: Fastest Path to Approval

  1. Oncologist Verification (Provider responsibility)
  2. Gather Required Documentation (Patient/Clinic)
    • Pathology report confirming medullary thyroid cancer
    • Imaging showing metastatic disease progression
    • Timeline: Collect within 1-2 weeks
    • Source: Medical records department
  3. Complete PA Submission (Provider)
    • Use UnitedHealthcare Provider Portal
    • Include ICD-10 codes and clinical notes
    • Timeline: Submit 3-4 weeks before needed
    • Expected response: 72 hours for standard review
  4. Monitor PA Status (Patient/Provider)
    • Check portal daily after submission
    • Timeline: Decision within 72 hours
    • Follow-up: Call 866-889-8054 if delayed

Medical Necessity Criteria

For UnitedHealthcare approval, your oncologist must document:

  • Confirmed diagnosis: Progressive, metastatic medullary thyroid carcinoma with appropriate ICD-10 coding
  • Disease progression: Clinical or radiographic evidence of advancing cancer
  • Treatment appropriateness: Cometriq capsules (not Cabometyx tablets) prescribed at FDA-approved dosing
  • No contraindications: Patient can safely receive cabozantinib therapy
Clinician Corner: Include specific imaging dates showing progression, baseline lab values, and performance status in your medical necessity letter. Reference the FDA labeling for dosing and safety parameters.

Submission Portals & Upload Instructions

UnitedHealthcare Provider Portal

Primary submission method for all PA requests:

  • URL: UHCprovider.com
  • Registration: New users register at UHCprovider.com/access
  • Required uploads: Clinical documentation, pathology reports, imaging results
  • File formats: PDF, JPG, PNG (verify current requirements in portal)

Documentation Upload Process

  1. Log into Provider Portal
  2. Navigate to "Prior Authorization and Notification"
  3. Select member and drug (Cometriq/cabozantinib)
  4. Upload supporting documents:
    • Pathology report
    • Recent imaging studies
    • Clinical notes documenting progression
    • Lab results if relevant

Alternative Submission Methods

If portal access isn't available:

  • Phone PA line: 866-889-8054
  • 24/7 provider support: Available through portal chat
  • Fax backup: Use only when portal is unavailable (see contact section)

Fax Numbers & Mailing Addresses

UnitedHealthcare PA Contacts

Prior Authorization Fax:

  • Standard requests: Submit via provider portal (preferred)
  • Urgent/expedited: 866-373-1081
  • Cover sheet tip: Mark "URGENT - COMETRIQ PA" for expedited review

Appeals Mailing Address:

UnitedHealthcare
Member Grievance & Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364

Provider Support:

  • General inquiries: 800-600-9007 (Medicaid/Community Plans)
  • Commercial plans: Use number on member ID card
  • 24/7 chat available through provider portal
Note: Always include member ID, provider NPI, and drug name (Cometriq, NOT Cabometyx) on all correspondence.

Specialty Pharmacy Transfer Process

Cometriq must be filled through UnitedHealthcare's preferred specialty pharmacy network, typically OptumRx.

Transfer Steps

  1. Contact OptumRx: 1-855-427-4682
  2. Provide information:
    • Current prescription details
    • Previous pharmacy information
    • Insurance details
  3. Coordinate with prescriber: Ensure PA is approved before transfer
  4. Timeline: Allow 3-4 weeks for complete transfer and first fill

Financial Assistance

OptumRx offers support programs:

  • Copay assistance enrollment
  • Patient assistance program screening
  • Medicare Prescription Payment Plan (for Medicare beneficiaries)
  • 2025 benefit: $2,000 annual out-of-pocket maximum for Medicare Part D specialty drugs

Support Lines & Who to Call

Member Services

  • Primary number: On back of insurance card
  • Best times to call: Early morning or late afternoon
  • What to ask: PA status, appeal rights, specialty pharmacy requirements

Provider Services

  • PA support: 866-889-8054
  • Portal help: 24/7 chat through UHCprovider.com
  • Urgent PA: 866-373-1081 (fax for expedited review)

Case Management

For complex cases, request assignment to a case manager:

  • Call member services and ask for "case management"
  • Useful for coordinating multiple appeals or complex medical situations

Pennsylvania Appeals & External Review

Pennsylvania launched a new state-administered external review program in January 2024, giving UnitedHealthcare members powerful appeal rights.

Appeals Timeline

Level Deadline Decision Time How to Submit
Internal Appeal 12 months from EOB 15-30 days UHC Provider Portal or mail
External Review 4 months from final denial 45 days (72 hours if urgent) PA Insurance Dept

Pennsylvania External Review Success

2024 results: 259 of 517 appeals (50%) were overturned, forcing insurers to cover initially denied treatments.

How to Request External Review

  1. Complete internal appeals with UnitedHealthcare first
  2. Gather documents:
    • Final denial letter from UnitedHealthcare
    • Insurance card
    • Medical records supporting Cometriq necessity
  3. Submit request within 4 months via:

Consumer Assistance

Pennsylvania Insurance Department:

  • Phone: 1-877-881-6388
  • Email: [email protected]
  • No cost to consumers for external review
  • Staff available to help with application process

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documents
"Not medically necessary" Submit progression evidence Recent imaging, oncologist notes
Wrong formulation (Cabometyx vs Cometriq) Clarify capsule requirement Prescription specifying "Cometriq capsules"
Missing diagnosis documentation Provide pathology confirmation Pathology report with medullary thyroid cancer
Step therapy not completed Document contraindications to alternatives Clinical notes explaining why alternatives failed/inappropriate

Scripts for Common Situations

Patient script for member services: "I'm calling about a prior authorization denial for Cometriq capsules for metastatic medullary thyroid cancer. My oncologist says this is the appropriate treatment, and I'd like to understand the appeal process and what additional documentation is needed."

Provider script for peer-to-peer review: "I'm requesting a peer-to-peer review for Cometriq prior authorization. This patient has progressive, metastatic medullary thyroid carcinoma documented by [specific imaging/pathology]. Cometriq is FDA-approved for this indication and represents appropriate standard of care."

Update Schedule & Resource Maintenance

When to Re-check Resources

  • Quarterly: UnitedHealthcare updates PA requirements and formularies
  • Annually: Major policy changes typically effective January 1
  • As needed: Check after any denial or policy notification

Key Resources to Monitor

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by generating evidence-backed, payer-specific rebuttal letters. The platform ingests denial letters and clinical notes to identify denial reasons and draft targeted appeals aligned to each plan's specific criteria.

When you're navigating the complex world of specialty drug approvals, having expert support can make the difference between a successful appeal and continued treatment delays. Counterforce Health's platform specializes in transforming UnitedHealthcare denials into winning appeals by leveraging payer-specific workflows and requirements.

FAQ

How long does UnitedHealthcare PA take in Pennsylvania? Standard prior authorization decisions are made within 72 hours. Expedited reviews for urgent cases may be completed faster.

What if Cometriq is non-formulary on my plan? Even non-formulary drugs can be covered through the exception process. Submit a PA with strong medical necessity documentation.

Can I request an expedited appeal? Yes, if waiting for standard review could seriously jeopardize your health. Mark requests as "URGENT" and include physician certification.

Does step therapy apply if I've failed other treatments outside Pennsylvania? Prior treatment failures from other states count toward step therapy requirements. Include documentation of previous therapies and outcomes.

What's the difference between Cometriq and Cabometyx? Cometriq (capsules) and Cabometyx (tablets) contain the same drug but are NOT interchangeable. Ensure your prescription specifies "Cometriq capsules."

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for plan-specific guidance. Coverage policies and requirements may change. For personalized assistance with Pennsylvania insurance issues, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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