By Counterforce Health Team in Cometriq (cabozantinib) —

Getting Cometriq (Cabozantinib) Covered by UnitedHealthcare in New Jersey: Prior Authorization, Appeals, and Step Therapy Protections

Answer Box: Getting Cometriq (Cabozantinib) Covered by UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization for Cometriq (cabozantinib) capsules for metastatic medullary thyroid carcinoma (MTC) but does not require step therapy for this specific indication. Your fastest path: 1) Confirm MTC diagnosis with your oncologist, 2) Submit PA through UnitedHealthcare Provider Portal with diagnosis documentation, 3) If denied, file internal appeal within 180 days. New Jersey's step therapy reform law (effective January 2026) provides additional override protections for state-regulated plans.

Table of Contents

Why New Jersey State Rules Matter

New Jersey's insurance regulations interact with UnitedHealthcare's coverage policies in important ways, especially for specialty oncology drugs like Cometriq (cabozantinib). The state's regulatory framework affects how quickly your appeal gets processed, what protections you have against inappropriate step therapy, and your rights to external review.

Plan Type Differences:

  • State-regulated plans (individual/family ACA plans, small group): Subject to New Jersey insurance laws, including the new step therapy reform protections
  • Medicare Advantage: Follows federal Medicare rules but with some state oversight
  • Self-funded employer plans (ERISA): Limited state protections; primarily governed by federal law

Understanding which type of UnitedHealthcare plan you have determines your appeal rights and available protections.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for Cometriq capsules UnitedHealthcare PA Requirements UHC PA List 2025
Step Therapy for MTC Not required for medullary thyroid carcinoma Cometriq PA Policy UHC Clinical Policy
Approval Duration 12 months if criteria met Same policy document UHC Clinical Policy
Formulation Requirement Must use capsules, not Cabometyx tablets FDA labeling and PA policy FDA/UHC Policy
Internal Appeal Deadline 180 days from denial Plan documents Standard UHC Policy
External Review Deadline 180 days from final denial NJ IHCAP NJ DOBI/Maximus

UnitedHealthcare Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Cometriq through OptumRx, but the requirements vary by your specific diagnosis.

For Medullary Thyroid Carcinoma (MTC)

Good news: UnitedHealthcare's policy recognizes that MTC patients don't need to try other therapies first. According to their clinical PA policy, approval requires only:

  • Confirmed diagnosis of medullary thyroid carcinoma
  • Prescription from an oncologist
  • Documentation that disease is progressive/metastatic

For Other Thyroid Cancers

If you have follicular, oncocytic, or papillary thyroid carcinoma, step therapy applies—you must show progression after trying Lenvima (lenvatinib) or Nexavar (sorafenib) first.

Key Documentation Needed

  • Pathology report confirming MTC diagnosis
  • Oncologist's treatment plan
  • Imaging showing metastatic or progressive disease
  • Prior therapy history (if applicable)
Tip: Always specify "medullary thyroid carcinoma" clearly in all documentation. Generic terms like "thyroid cancer" may trigger unnecessary step therapy requirements.

New Jersey Step Therapy Protections

New Jersey enacted Assembly Bill A1825 in March 2025, with implementation starting January 1, 2026. This law provides significant protections for oncology patients, including those needing Cometriq.

Override Criteria

Under the new law, you can request immediate coverage (step therapy override) if:

  • The required first-line drug is contraindicated
  • You previously tried and failed the step therapy drug
  • The step therapy drug is expected to be ineffective
  • You're currently stable on your prescribed drug
  • The required drug is not in your best interest

Timeline Requirements

Plans must respond to override requests within:

  • 24 hours for urgent requests
  • 72 hours for non-urgent requests

Who Can Request

Both patients and healthcare providers can request step therapy overrides with proper documentation.

Note: These protections apply to state-regulated plans. ERISA (self-funded employer) plans are not subject to New Jersey's step therapy law but may voluntarily adopt similar policies.

Appeals Process and Timelines

If your Cometriq prior authorization is denied, New Jersey provides a structured appeals process with specific timelines.

Internal Appeals (UnitedHealthcare)

Standard Appeals:

  • Deadline: 180 days from denial date
  • Timeline: UnitedHealthcare has 30 days to respond (15 days for urgent appeals)
  • How to file: UnitedHealthcare member portal, phone, or written appeal

Required for Internal Appeal:

  • Copy of denial letter
  • Medical records supporting medical necessity
  • Physician letter addressing denial reasons
  • Any additional clinical evidence

Medicare Advantage Appeals

If you have UnitedHealthcare Medicare Advantage, follow the federal Medicare appeals process:

  1. Redetermination (plan level): 7-14 days
  2. Independent Review Entity: 30 days
  3. Administrative Law Judge: If amount exceeds $180 (2025 threshold)

External Review Through IHCAP

After exhausting UnitedHealthcare's internal appeals, New Jersey residents can access the Independent Health Care Appeals Program (IHCAP), administered by Maximus Federal Services.

Eligibility

  • Completed all internal appeals with UnitedHealthcare
  • Denial based on medical necessity, experimental treatment, or similar coverage issues
  • Filed within 180 days of final internal denial

How to File

Submit through the Maximus IHCAP Portal or mail documents to the address provided by Maximus.

Timeline

  • Standard review: Decision within 45 days
  • Expedited review: Decision within 48 hours (for urgent cases)

Success Rates

Approximately 50% of external reviews nationwide overturn insurer denials, with higher success rates when robust medical documentation is provided.

From our advocates: We've seen cases where patients initially denied Cometriq received approval after external review when their oncologist provided a detailed letter explaining why alternative treatments weren't appropriate for their specific MTC subtype. The key was addressing each denial reason point-by-point with current medical literature.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide oncologist letter with clinical rationale Treatment history, imaging, pathology
Wrong formulation (Cabometyx vs Cometriq) Emphasize MTC-specific FDA approval FDA labeling, diagnosis confirmation
Missing prior authorization Submit complete PA with all requirements Diagnosis, treatment plan, medical records
Step therapy not completed Request override citing MTC-specific policy MTC diagnosis, contraindication documentation

Scripts and Templates

Patient Phone Script for UnitedHealthcare

"Hello, I'm calling about my prior authorization request for Cometriq capsules for metastatic medullary thyroid carcinoma. My reference number is [PA number]. According to your clinical policy, step therapy doesn't apply to MTC patients. Can you confirm the status and what additional documentation you need?"

Medical Necessity Letter Template

Your oncologist should address:

  • Specific MTC diagnosis with pathology confirmation
  • Disease progression/metastatic status
  • Why Cometriq is appropriate first-line therapy for MTC
  • Expected treatment duration and monitoring plan
  • References to FDA labeling and clinical guidelines

Costs and Patient Assistance

Cometriq costs approximately $18,938 for a 112-capsule pack (verify with current pricing). Financial assistance options include:

Manufacturer Support

  • Exelixis Patient Support Program: Copay assistance and patient support services
  • Contact: Check Cometriq.com for current program details

Foundation Assistance

  • Patient advocacy organizations often provide grants for specialty oncology medications
  • Check eligibility requirements and application deadlines

State Programs

  • New Jersey may have additional pharmaceutical assistance programs for residents

When to Escalate

Contact New Jersey regulators if you experience:

  • Repeated inappropriate denials
  • Failure to meet appeal timelines
  • Lack of response to valid override requests

New Jersey Department of Banking and Insurance:

  • Consumer Hotline: 1-800-446-7467
  • IHCAP Help Line: 1-888-393-1062

For Medicare Advantage issues, contact 1-800-MEDICARE for additional assistance.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes by analyzing denial letters and crafting evidence-backed appeals that address payer-specific requirements. Their platform specializes in turning insurance denials into targeted rebuttals using the right clinical documentation and regulatory citations. Learn more at CounterforceHealth.org.

FAQ

How long does UnitedHealthcare prior authorization take for Cometriq in New Jersey? Standard PA decisions typically take 15-30 days. Urgent requests may be processed within 72 hours if properly documented.

What if Cometriq is not on my UnitedHealthcare formulary? Even non-formulary drugs can be covered with prior authorization and medical necessity documentation. Request a formulary exception through the PA process.

Can I get expedited appeals in New Jersey? Yes, both UnitedHealthcare internal appeals and New Jersey external reviews offer expedited processing for urgent medical situations.

Does step therapy apply if I tried alternatives outside New Jersey? Prior therapy history from any location counts toward step therapy requirements. Provide documentation of previous treatments and outcomes.

What's the difference between Cometriq and Cabometyx for insurance? Cometriq (capsules) is FDA-approved for MTC; Cabometyx (tablets) is not. Insurance will only cover the appropriate formulation for your diagnosis.

How do I know if my plan is subject to New Jersey's step therapy protections? State-regulated plans (individual/family, small group) are covered. Large employer self-funded plans (ERISA) typically are not, but check your plan documents.

What happens if I miss an appeal deadline? Contact the plan immediately to request an extension. Some circumstances (like not receiving proper notice) may allow late appeals.

Can my doctor request peer-to-peer review? Yes, UnitedHealthcare typically offers peer-to-peer consultations where your oncologist can discuss the case directly with their medical director.

Sources & Further Reading

This guide is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact qualified professionals for specific insurance or legal questions. For additional help with complex prior authorization cases, consider working with specialized advocacy services like Counterforce Health, which helps turn insurance denials into successful appeals through targeted, evidence-based documentation.

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