By Counterforce Health Team in Cometriq (cabozantinib) —

Getting Cometriq (Cabozantinib) Approved by Aetna CVS Health in Washington: Timeline, Appeals, and Approval Scripts

Answer Box: Fast-Track Your Cometriq Approval

Getting Cometriq (cabozantinib) covered by Aetna CVS Health in Washington typically takes 1-5 days with complete documentation. Submit prior authorization via Aetna's provider portal or call 1-866-814-5506 for specialty medications. Include medullary thyroid carcinoma diagnosis, prior treatment history, and clinical justification. If denied, file an internal appeal within 180 days, then request external review through Washington's Office of the Insurance Commissioner within 60 days for a binding decision.

Table of Contents

  1. What Affects Cometriq Approval Timeline
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Reading Results
  6. If Denied: Washington Appeal Process
  7. Renewal Cycles & Ongoing Coverage
  8. Timeline Visual & Milestones
  9. Time-Saving Tips for Faster Approval
  10. Common Denial Reasons & Solutions
  11. Clinician Corner: Medical Necessity Documentation
  12. Patient Scripts & Templates
  13. FAQ: Cometriq Coverage Questions

What Affects Cometriq Approval Timeline

Several factors influence how quickly Aetna CVS Health processes your Cometriq (cabozantinib) prior authorization in Washington:

Benefit Type Impact:

  • Commercial plans: Standard 5-7 business days
  • Medicare Advantage: 72 hours for urgent, 14 days standard
  • Medicaid managed care: Follows Washington state timelines

Complexity Factors:

  • Complete documentation speeds approval by 2-3 days
  • Off-label use requires additional clinical evidence
  • Prior authorization history with Aetna affects processing
  • Specialty pharmacy coordination may add 1-2 days

Documentation Completeness: Missing clinical notes or prior therapy records typically delay approval by 3-5 days while Aetna requests additional information.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Patient Information:

  • Aetna member ID and group number
  • Complete contact information
  • Washington state residency verification

Clinical Documentation:

  • Confirmed medullary thyroid carcinoma diagnosis with pathology
  • ICD-10 code: C73 (malignant neoplasm of thyroid gland)
  • Prior treatment history and outcomes
  • Current staging and disease progression notes
  • Prescriber DEA number and NPI

Insurance Verification:

  • Current formulary status (Cometriq typically Tier 4 specialty)
  • Prior authorization requirements confirmation
  • Quantity limits: Usually 112 capsules per 28 days for 140mg daily dose
Tip: Call Aetna at 1-800-294-5979 to verify current PA requirements before submitting. This prevents common delays from outdated forms or missing documentation.

Submission to Initial Review (1-5 Days)

How to Submit Your Prior Authorization

Electronic Submission (Fastest - Often Same Day):

Phone/Fax Options:

  • Specialty medications: 1-866-814-5506
  • Fax: 1-866-249-6155
  • Non-specialty backup: 1-800-294-5979

What Reviewers Check First:

  1. Valid prescription with correct NDC codes
  2. Diagnosis matches FDA-approved indication
  3. Prescriber credentials and specialty
  4. Prior therapy documentation
  5. Quantity and dosing appropriateness

Washington state requires insurers to acknowledge receipt within 1 business day and provides expedited review for urgent cases affecting patient safety.

Additional Information Requests (1-7 Days)

If Aetna requests additional information, respond within 14 days to avoid automatic denial. Common requests include:

Clinical Clarification:

  • More detailed treatment history
  • Staging information or imaging reports
  • Contraindications to alternative therapies
  • Expected treatment duration

Administrative Items:

  • Updated prescriber information
  • Correct diagnosis codes
  • Prior authorization forms completion
Note: Respond to information requests via the same method used for initial submission. Electronic responses process fastest, typically within 24-48 hours.

Decision Window & Reading Results

Typical Aetna Decision Timeframes

Submission Type Standard Timeline Expedited Timeline
Electronic PA 24-72 hours Same day possible
Fax/Phone 3-5 business days 72 hours
Complex Cases 5-10 business days 5 days

Reading Your Approval Letter:

  • Approved: Includes quantity limits, refill authorization, and CVS Specialty contact information
  • Approved with Modifications: May require dosage adjustments or monitoring requirements
  • Denied: Provides specific denial reason and appeal rights information

If Denied: Washington Appeal Process

Washington state provides robust appeal rights for Aetna denials, with multiple levels of review.

Internal Appeal Process

Timeline to File: Within 180 days of denial notice Aetna's Response Time: 45 business days (72 hours for urgent) How to Submit:

  • Online: Aetna Appeals Portal
  • Mail: Aetna Appeals Resolution Team, PO Box 14020, Lexington, KY 40512
  • Fax: Number provided on denial letter

External Review (IRO) Process

If internal appeal fails, Washington law provides independent external review:

Timeline: Request within 60 days of internal appeal denial Process: Contact Washington Office of the Insurance Commissioner Decision Timeline: 45 days standard, 72 hours expedited Cost: No fee to patient Binding: Decision is final and binding on Aetna

OIC Contact Information:

  • Phone: 1-800-562-6900
  • Online: File complaint at insurance.wa.gov
  • Address: Office of the Insurance Commissioner, PO Box 40255, Olympia, WA 98504-0255

Renewal Cycles & Ongoing Coverage

Cometriq requires annual reauthorization with Aetna CVS Health, typically aligned with your plan year (January 1st renewal for most commercial plans).

Renewal Requirements:

  • Updated clinical assessment showing continued medical necessity
  • Disease progression or stability documentation
  • Tolerance and response to therapy
  • Absence of contraindications

Timeline for Renewal: Submit reauthorization 30-45 days before current approval expires to prevent treatment interruption.

Mid-Year Changes: Aetna may modify coverage due to formulary updates, but existing patients typically receive continuation rights through the plan year.

Timeline Visual & Milestones

Cometriq Approval Timeline

Day 0: Submit complete PA
Day 1-2: Aetna acknowledgment & initial review
Day 3-5: Clinical review & decision
Day 6-7: Approval letter & CVS Specialty coordination
Day 8-10: Medication dispensed & shipped

If Denied:
Day 1-180: File internal appeal
Day 181-240: External review request window

Expedited Timeline for Urgent Cases:

  • Same day to 72 hours for approval
  • Must document immediate health risk from delay

Time-Saving Tips for Faster Approval

  1. Use Electronic Submission: Availity or CoverMyMeds process 60% faster than fax
  2. Bundle All Evidence: Include complete clinical package with initial submission
  3. Specialty Routing: Call 1-866-814-5506 directly for specialty medication PAs
  4. Pre-Verify Coverage: Confirm formulary status before prescribing
  5. Template Letters: Use standardized medical necessity templates
  6. Follow Up Proactively: Check status after 3 business days if no response

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Non-formulary status Request formulary exception Clinical superiority evidence
Step therapy not met Document failures/intolerances Prior therapy records
Quantity limit exceeded Justify higher dose Weight-based dosing rationale
Diagnosis not supported Provide pathology confirmation Biopsy reports, staging
Off-label use Submit clinical evidence Peer-reviewed studies, guidelines

Clinician Corner: Medical Necessity Documentation

Essential Elements for Approval

Clinical Rationale Must Include:

  1. Confirmed medullary thyroid carcinoma diagnosis
  2. Disease staging and progression status
  3. Prior therapies attempted and outcomes
  4. Contraindications to alternatives (vandetanib)
  5. Expected treatment goals and monitoring plan

Supporting Evidence:

  • FDA prescribing information for Cometriq
  • NCCN Guidelines for Thyroid Carcinoma
  • Pathology reports confirming MTC diagnosis
  • Imaging showing progressive disease

Documentation Template: "Patient has confirmed metastatic medullary thyroid carcinoma with progressive disease despite [prior therapy]. Cometriq is FDA-approved for this indication and represents standard of care. Patient has no contraindications and will be monitored per protocol."

Patient Scripts & Templates

Calling Aetna Customer Service

"Hi, I'm calling about prior authorization for Cometriq, generic name cabozantinib, for my medullary thyroid cancer. My member ID is [number]. Can you tell me the status of my PA request submitted on [date]? If it's denied, I'd like to understand the specific reason and my appeal options."

Requesting Expedited Review

"My doctor says I need expedited review for Cometriq because my cancer is progressing rapidly. This is for medullary thyroid carcinoma, and any delay in starting treatment could seriously affect my health outcomes."

FAQ: Cometriq Coverage Questions

How long does Aetna CVS Health PA take in Washington? Standard prior authorization typically takes 3-5 business days with complete documentation. Electronic submissions often process within 24-72 hours.

What if Cometriq is non-formulary on my plan? Request a formulary exception by demonstrating medical necessity and lack of suitable alternatives. Include clinical evidence supporting Cometriq's superiority for your specific case.

Can I request expedited appeal in Washington? Yes, if delay would seriously jeopardize your health. Mark requests as "urgent" and provide clinical documentation of immediate medical need.

Does step therapy apply to Cometriq? Some Aetna plans require trying vandetanib first. Document contraindications, intolerances, or clinical reasons why Cometriq is preferred.

What's the cost with Aetna coverage? Specialty tier copays typically range from $100-500/month. Check your specific plan documents or call member services for exact amounts.

How do I find CVS Specialty Pharmacy information? After approval, Aetna will provide CVS Specialty contact information. You can also call 1-800-237-2767 for specialty pharmacy services.

What if my employer plan is self-funded? Self-funded plans may not follow Washington state appeal laws. Contact your HR department for plan-specific appeal procedures, or file with the U.S. Department of Labor if needed.

Can my doctor do a peer-to-peer review? Yes, request peer-to-peer review during the appeal process. This allows your oncologist to speak directly with Aetna's medical director about your case.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to create targeted rebuttals that align with each payer's specific requirements, significantly improving approval rates for specialty medications like Cometriq.

For complex cases requiring additional support, Counterforce Health provides automated appeal generation that pulls the right clinical evidence, regulatory citations, and payer-specific documentation to build compelling cases for coverage approval.

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 plan documents for specific coverage details. Coverage policies and procedures may change; verify current requirements with Aetna CVS Health and Washington state regulators.

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