By Counterforce Health Team in Cometriq (cabozantinib) —

Getting Cometriq (Cabozantinib) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Prior Authorization and Appeals Guide

Quick Answer: Cometriq requires prior authorization from Blue Cross Blue Shield plans in Pennsylvania. You'll need: (1) diagnosis of metastatic medullary thyroid carcinoma with ICD-10 code C73, (2) prescription from an oncologist, and (3) submission through specialty pharmacy networks only. If denied, you have 180 days for internal appeals and 4 months for Pennsylvania's external review. Start by contacting your prescriber's office to initiate the prior authorization process today.

Table of Contents

What Drives Cometriq Coverage Costs

Understanding your Blue Cross Blue Shield plan's benefit design helps predict your out-of-pocket costs for Cometriq (cabozantinib). Several factors determine what you'll pay:

Formulary Tier Placement Cometriq appears on Blue Cross Blue Shield formularies in Pennsylvania, including Capital Blue Cross 2025 Elite formulary and Highmark Blue Cross Blue Shield. Higher tiers typically mean higher copays—specialty drugs often fall into Tier 4 or 5 with coinsurance rather than flat copays.

Specialty Drug Classification Cometriq is classified as a specialty medication requiring dispensing through approved specialty pharmacy networks. This classification often means different cost-sharing structures than regular prescriptions, with monthly coinsurance ranging from 20-50% of the drug's cost.

Medical vs. Pharmacy Benefit Cometriq is covered under your pharmacy benefit, not medical benefit. This distinction matters because deductibles, out-of-pocket maximums, and prior authorization processes differ between these benefit categories.

Investigating Your Blue Cross Blue Shield Benefits

Before starting treatment, gather specific information about your coverage:

Essential Information to Collect:

  • Your specific Blue Cross Blue Shield plan name and member ID
  • Specialty pharmacy tier copay or coinsurance percentage
  • Annual out-of-pocket maximum for pharmacy benefits
  • Whether you've met your deductible for the current year
  • Prior authorization requirements and approval status

Questions to Ask Your Plan:

  1. "What is my copay or coinsurance for specialty tier medications?"
  2. "Which specialty pharmacies are in-network for Cometriq?"
  3. "Has prior authorization been approved for Cometriq with diagnosis code C73?"
  4. "What is my remaining out-of-pocket maximum for this year?"

Where to Find Information:

  • Member portal or mobile app
  • Summary of Benefits and Coverage (SBC) document
  • Customer service line (number on your insurance card)
  • Explanation of Benefits (EOB) from previous specialty medications

Patient Assistance and Cost Support Options

Multiple programs can help reduce your Cometriq costs, depending on your insurance type and financial situation.

Exelixis Access Services (EASE) Exelixis offers comprehensive financial support through EASE:

  • Commercial Insurance Copay Program: Eligible patients may pay as little as $0 per month
  • Patient Assistance Program: Free medication for qualifying uninsured patients
  • Coverage Support: Case managers help navigate insurance requirements
Note: Copay assistance is not available for government-funded insurance (Medicare, Medicaid, TRICARE) or where prohibited by law.

Foundation Grants Several patient advocacy foundations provide grants for cancer medications:

  • Patient Advocate Foundation Co-Pay Relief Program
  • CancerCare Co-Payment Assistance Foundation
  • HealthWell Foundation Thyroid Cancer Fund

Enrollment Process To access EASE support:

  1. Your healthcare provider initiates the EASE Enrollment Form
  2. Complete the Patient Authorization Form
  3. Submit online, by fax to 1-844-901-EASE, or in your provider's office
  4. Case managers will contact you about available assistance

Prior Authorization Requirements

Prior authorization is mandatory for Cometriq coverage through Blue Cross Blue Shield plans in Pennsylvania. The process typically takes approximately one day for standard requests, with over 45% of authorizations now automated at submission.

Coverage Requirements Table

Requirement Details Source
Diagnosis Metastatic medullary thyroid carcinoma (ICD-10: C73) PA Health and Wellness Policy
Prescriber Oncologist or consultation with oncologist PA Health and Wellness
Age Patient ≥ 18 years PA Health and Wellness
Formulation Cometriq capsules specifically (not Cabometyx tablets) Counterforce Health
Documentation Progressive, metastatic disease evidence PA Health and Wellness
Approval Duration 6 months initially PA Health and Wellness

Critical Formulation Distinction

Cometriq vs. Cabometyx: These medications contain the same active ingredient but are not interchangeable for insurance purposes. Cometriq capsules are FDA-approved specifically for metastatic medullary thyroid carcinoma, while Cabometyx tablets are approved for different cancer types. Using the wrong formulation triggers automatic denial.

Required Clinical Documentation

Your healthcare provider must include:

  • Two or more serum calcitonin measurements after surgery
  • Surgical history (total thyroidectomy or lobectomy)
  • Documentation of progressive disease or metastatic spread
  • Prior treatment history and outcomes
  • Current performance status

Specialty Pharmacy Requirements

Cometriq must be dispensed through Blue Cross Blue Shield's approved specialty pharmacy networks. Attempting to fill at retail pharmacies results in automatic denial regardless of prescription benefits.

Approved Submission Methods:

  • Electronic submission via Availity Essentials platform
  • CoverMyMeds for some Blue Cross Blue Shield plans
  • Direct submission through specialty pharmacy benefit management

Common Submission Errors to Avoid:

  • Using Cabometyx NDC codes instead of Cometriq capsule codes
  • Submitting under medical benefit instead of pharmacy benefit
  • Missing ICD-10 code C73 for thyroid cancer
  • Attempting retail pharmacy fills
Tip: Confirm specialty pharmacy network participation before starting the prior authorization process to avoid delays.

Appeals Process in Pennsylvania

If your Blue Cross Blue Shield plan denies coverage for Cometriq, Pennsylvania offers robust appeal rights with recent improvements to the external review process.

Internal Appeals Timeline

  1. Initial Denial: You have 180 days to file an internal appeal
  2. Standard Review: Decision within 30 days for non-urgent requests
  3. Expedited Review: Decision within 72 hours for urgent medical situations
  4. Final Adverse Determination: Triggers eligibility for external review

Pennsylvania External Review Process

Pennsylvania launched its Independent External Review Program in January 2024, providing state-supervised appeals with a 50% success rate in the first year.

External Review Steps:

  1. Eligibility: Must complete internal appeals and receive Final Adverse Benefit Determination
  2. Deadline: File within 4 months of insurer's final decision
  3. Submission: Online via PA.gov or by mail/fax
  4. Timeline: 45 days for standard review, 72 hours for expedited
  5. Decision: Binding on the insurer

Required Documents for Appeals:

  • Original denial letter and Final Adverse Determination
  • Complete medical records supporting medical necessity
  • Physician statement explaining clinical rationale
  • Evidence of failed alternative treatments (if applicable)
  • Peer-reviewed literature supporting Cometriq use for your condition

When to Request Expedited Appeals

Request expedited processing if:

  • Delaying treatment could seriously jeopardize your health
  • You're experiencing disease progression requiring immediate intervention
  • Your oncologist certifies urgent medical need

Annual Renewal and Budget Planning

Plan ahead for potential changes that could affect your Cometriq coverage and costs:

What Can Change Annually:

  • Formulary tier placement (higher or lower tiers)
  • Prior authorization requirements (new restrictions or relaxed criteria)
  • Specialty pharmacy network participation
  • Copay or coinsurance percentages
  • Annual deductible and out-of-pocket maximums

Renewal Preparation Checklist:

  • Review your plan's Summary of Benefits for the upcoming year
  • Verify Cometriq remains on formulary at the same tier
  • Confirm your specialty pharmacy remains in-network
  • Update EASE enrollment if changing plans
  • Schedule year-end provider visits to document continued medical necessity

Budget Planning Tips:

  • Calculate maximum annual out-of-pocket costs under your plan
  • Factor in potential formulary changes when choosing plans during open enrollment
  • Consider Health Savings Account (HSA) contributions if eligible
  • Document all treatment-related expenses for tax deduction purposes

Conversation Scripts

Calling Blue Cross Blue Shield Customer Service

"Hello, I'm calling about prior authorization for Cometriq, spelled C-O-M-E-T-R-I-Q, for metastatic medullary thyroid carcinoma. My member ID is [ID number]. Can you tell me the status of the prior authorization request submitted by [provider name] and what specialty pharmacies are in-network for this medication?"

Provider Office Script for Prior Authorization

"We need to submit a prior authorization for Cometriq capsules—not Cabometyx tablets—for a patient with metastatic medullary thyroid carcinoma, ICD-10 code C73. The patient is over 18, and we have documentation of progressive disease and prior surgical history. Should we submit through Availity Essentials or another platform for this Blue Cross Blue Shield plan?"

Peer-to-Peer Review Request

"I'm requesting a peer-to-peer review for a denied Cometriq prior authorization. The patient has confirmed metastatic medullary thyroid carcinoma with rising calcitonin levels post-surgery and documented disease progression. Cometriq is FDA-approved specifically for this indication, and the patient meets all coverage criteria outlined in your policy."

FAQ

How long does Blue Cross Blue Shield prior authorization take in Pennsylvania? Standard requests typically receive decisions within one day, with over 45% of authorizations automated at submission. Expedited requests for urgent medical situations are decided within 72 hours.

What if Cometriq is non-formulary on my Blue Cross Blue Shield plan? You can request a formulary exception by demonstrating medical necessity, contraindications to covered alternatives, or prior treatment failures. Include peer-reviewed evidence and your oncologist's clinical rationale.

Can I request an expedited appeal if my initial authorization is denied? Yes, if your oncologist certifies that delaying treatment could seriously jeopardize your health. Expedited appeals are decided within 72 hours for both internal and external reviews.

Does step therapy apply if I've tried other treatments outside Pennsylvania? Yes, prior treatment history from other states counts toward step therapy requirements. Ensure your provider documents all prior therapies, including dates, dosages, and reasons for discontinuation.

What happens if I change Blue Cross Blue Shield plans mid-treatment? You'll need new prior authorization under the new plan's criteria. Contact EASE case managers to update your enrollment and ensure continuity of financial assistance.

How much does Cometriq cost without insurance in Pennsylvania? Cash prices show approximately $18,938 for a 112-capsule "140 mg daily-dose" pack. Patient assistance programs through EASE may provide free medication for qualifying uninsured patients.

Can I use a retail pharmacy for Cometriq if I pay cash? While retail pharmacies can dispense Cometriq for cash payments, insurance coverage requires specialty pharmacy dispensing. Using retail pharmacies will result in coverage denial even with valid prior authorization.

What's the difference between Cometriq and Cabometyx for insurance purposes? Cometriq capsules and Cabometyx tablets contain the same active ingredient but have different FDA approvals and are not interchangeable for insurance coverage. Cometriq is approved for medullary thyroid carcinoma; Cabometyx is not.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes, then identifies the denial basis and drafts point-by-point rebuttals aligned to the plan's own rules. Learn more at www.counterforcehealth.org.

When navigating complex prior authorizations and appeals, having expert support can make the difference between approval and continued denials. Counterforce Health specializes in transforming insurance denials into successful appeals by leveraging payer-specific workflows and evidence-based strategies tailored to each plan's requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies vary by plan and state. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for current coverage information. For assistance with insurance appeals and prior authorizations, contact the Pennsylvania Insurance Department's Consumer Services Bureau.

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