By Counterforce Health Team in Cometriq (cabozantinib) —

Getting Cometriq (Cabozantinib) Covered by Humana in Michigan: Complete Prior Authorization and Appeals Guide

Answer Box: Fast Track to Cometriq Coverage

To get Cometriq (cabozantinib) covered by Humana in Michigan: Your doctor must submit a prior authorization request through Humana's provider portal or by calling 800-555-2546, including diagnosis of metastatic medullary thyroid carcinoma, elevated calcitonin levels, and documentation that Cometriq capsules (not Cabometyx tablets) are medically necessary. If denied, you have 65 days to appeal, and Michigan offers external review through DIFS within 127 days. Start today: Contact your prescriber to begin the PA request and gather your pathology report confirming MTC diagnosis.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Must be approved before filling Humana PA List Humana Provider Portal
Diagnosis Metastatic medullary thyroid carcinoma only Pathology report with CAP protocol FDA Label
Biomarkers Elevated calcitonin levels documented Lab results within 90 days Clinical requirement
Formulation Cometriq capsules specifically (not Cabometyx tablets) Prescription must specify capsules FDA Orange Book
Appeal Deadline 65 days from denial notice Denial letter date CMS Medicare Appeals
Michigan External Review 127 days after final internal denial DIFS Form FIS 0018 Michigan DIFS

Patient Profile: Understanding Your Diagnosis

If you've been diagnosed with metastatic medullary thyroid carcinoma (MTC), you're dealing with a rare but aggressive form of thyroid cancer. Unlike more common thyroid cancers, MTC doesn't respond to radioactive iodine treatment, making targeted therapies like Cometriq essential for managing disease progression.

Your oncologist has likely confirmed your diagnosis through several key tests:

  • Fine needle aspiration (FNA) biopsy showing characteristic MTC cells
  • Elevated calcitonin levels in your blood (often dramatically high)
  • Imaging studies (CT, MRI, or PET scans) showing metastatic spread
  • Genetic testing for RET mutations (found in about 25% of cases)

These diagnostic elements aren't just medical details—they're the foundation of your insurance approval. Humana requires documentation of progressive, metastatic disease with elevated biomarkers to approve Cometriq coverage.

Pre-Authorization Preparation

Step 1: Gather Essential Documentation

Your healthcare team needs to compile a comprehensive medical file before submitting to Humana:

  • Pathology report using College of American Pathologists (CAP) protocol with MTC confirmation
  • Recent calcitonin and CEA levels (within 90 days)
  • Staging scans showing metastatic disease progression
  • Prior therapy history including any previous treatments and their outcomes
  • Current performance status and treatment goals

Step 2: Medical Necessity Letter Components

Your oncologist's letter to Humana should address these key points:

  • Confirmed diagnosis of progressive, metastatic MTC
  • Documentation that disease is not amenable to surgery or radiation
  • Evidence of elevated calcitonin levels indicating active disease
  • Statement that Cometriq capsules (not Cabometyx tablets) are specifically indicated for MTC
  • Treatment goals and monitoring plan
Clinician Corner: Include specific calcitonin values and trend over time. Humana reviewers look for objective evidence of disease activity, not just imaging progression.

Submission Process

Option 1: Provider Portal (Fastest)

  1. Log into Humana Provider Portal
  2. Navigate to Prior Authorization section
  3. Complete "Request for Medicare Prescription Drug Coverage Determination"
  4. Upload all supporting documentation
  5. Submit electronically

Option 2: Phone Submission

  • Call Clinical Pharmacy Review: 800-555-2546 (Mon-Fri, 8 a.m.-8 p.m. ET)
  • Request drug-specific PA form for Cometriq
  • Fax completed form to 877-486-2621

Option 3: Mail Submission

CarePlus Health Plans
Attention: Clinical Pharmacy Review
P.O. Box 14601
Lexington, KY 40512-4601

Timeline Expectations:

  • Standard decision: Within 72 hours
  • Expedited (if urgent): Within 24 hours
  • You'll receive written notification of the decision

Initial Outcome: Approval or Denial

If Approved: Your approval letter will specify:

  • Approved quantity (typically 112 capsules for 28-day supply)
  • Duration of approval (usually 6-12 months)
  • Any quantity limits or dispensing restrictions
  • Renewal requirements

If Denied: Common denial reasons include:

  • Insufficient documentation of MTC diagnosis
  • Missing calcitonin levels or biomarker evidence
  • Prescription written for Cabometyx instead of Cometriq
  • Lack of medical necessity justification

Don't panic if you receive a denial. Many initial denials are overturned on appeal when proper documentation is provided.

Appeals Process in Michigan

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • Method: Use Humana's redetermination request form
  • Timeline: Decision within 30 days (72 hours if expedited)
  • Requirements: Submit additional medical evidence addressing denial reasons

External Review Through Michigan DIFS If Humana upholds the denial, Michigan residents have robust external review rights:

  • Deadline: 127 days after final internal denial
  • Form: DIFS Form FIS 0018
  • Timeline: Up to 60 days (72 hours if expedited)
  • Cost: Free to patients
  • Decision: Binding on Humana

Expedited External Review: For urgent cancer treatment needs, Michigan offers 72-hour expedited review. Your oncologist must provide a letter stating that delay would "seriously jeopardize your life, health, or ability to regain maximum function."

From Our Advocates: We've seen several Cometriq denials overturned at the Michigan external review level when patients included detailed oncology records and a strong physician letter emphasizing the urgency of controlling progressive MTC. The key is comprehensive documentation that clearly establishes medical necessity.

Contact DIFS for Help:

  • Phone: 877-999-6442
  • Online portal: difs.state.mi.us
  • Email support available through their portal

Resolution and Follow-Up

Once approved, your Cometriq coverage typically includes:

  • 30-day supplies through specialty pharmacy
  • Copay assistance eligibility through manufacturer programs
  • Renewal requirements every 6-12 months with updated labs and imaging
  • Monitoring protocols for side effects and disease response

Your oncology team should coordinate with the specialty pharmacy for delivery logistics and provide ongoing documentation for renewal approvals.

Common Denial Reasons & How to Fix Them

Denial Reason Solution Required Documentation
"Cabometyx prescribed instead of Cometriq" Resubmit with correct formulation New prescription specifying Cometriq capsules
"Insufficient MTC diagnosis documentation" Provide complete pathology report CAP protocol report with MTC confirmation
"Missing biomarker evidence" Submit recent lab work Calcitonin and CEA levels within 90 days
"Not medically necessary" Enhanced physician letter Detailed treatment history and disease progression
"Step therapy not completed" Document contraindications to alternatives Medical records showing why other treatments aren't suitable

Costs and Financial Assistance

Cash Price: Cometriq typically costs around $18,938 for a 112-capsule monthly supply.

Manufacturer Assistance:

  • Exelixis Patient Access Program (EASE): May reduce copays to as little as $25/month for eligible patients
  • Income requirements: Varies based on insurance type and household income
  • Application: Available through Cometriq.com or by calling 1-855-500-3273

Additional Resources:

  • CancerCare Copay Assistance Program
  • Patient Access Network Foundation
  • HealthWell Foundation (thyroid cancer fund)

Counterforce Health specializes in helping patients navigate complex prior authorization and appeals processes for specialty medications like Cometriq. Their platform can help identify the specific denial reasons and draft targeted appeals that address payer requirements point-by-point, potentially saving weeks in the approval process.

FAQ

How long does Humana prior authorization take for Cometriq in Michigan? Standard decisions are made within 72 hours. Expedited requests (for urgent medical needs) are processed within 24 hours.

What if Cometriq is not on Humana's formulary? You can request a formulary exception. Your doctor must demonstrate that formulary alternatives are ineffective or cause adverse effects for your specific condition.

Can I appeal a denial if I live in Michigan? Yes. Michigan residents have 65 days to file an internal appeal with Humana, followed by up to 127 days to request external review through Michigan DIFS.

Does step therapy apply to Cometriq for MTC? Typically no, since Cometriq is the only FDA-approved targeted therapy specifically for metastatic MTC. However, some plans may require documentation that surgery or radiation aren't options.

What's the difference between Cometriq and Cabometyx? Both contain cabozantinib but have different FDA approvals. Cometriq capsules are specifically approved for metastatic MTC, while Cabometyx tablets are for kidney and liver cancers. They're not interchangeable.

Can my doctor request a peer-to-peer review? Yes. If the initial PA is denied, your oncologist can request a peer-to-peer discussion with Humana's medical director to discuss your case directly.

How often do I need to renew prior authorization? Typically every 6-12 months, with updated imaging, lab work, and physician assessment of treatment response.

What if I need Cometriq urgently while waiting for approval? Ask your doctor about requesting expedited review (24-hour decision) and consider manufacturer assistance programs for temporary supply.

Sources & Further Reading

For personalized assistance with your Cometriq prior authorization or appeal, Counterforce Health offers specialized support for patients navigating insurance coverage for complex specialty medications.

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 for guidance specific to your situation. Coverage policies and procedures may change; verify current requirements with your insurer.

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