By Counterforce Health Team in Cometriq (cabozantinib) —

How Long Does It Take to Get Cometriq (Cabozantinib) Approved by Cigna in Washington? Complete Timeline Guide

Answer Box: Cometriq (Cabozantinib) Approval Timeline with Cigna in Washington

Fastest path to approval: Electronic prior authorization (PA) through Cigna/Express Scripts typically takes 1-3 business days in Washington once complete documentation is received. For urgent cases, expedited review decisions come within 24 hours.

First step today: Have your oncologist submit an electronic PA via CoverMyMeds or Cigna's provider portal with complete MTC diagnosis documentation, staging, and prior therapy history. Mark as expedited if treatment delay could jeopardize your health.

If denied: Internal appeals must be decided within 72 hours for urgent cases, with external review by Washington's Independent Review Organization available within 180 days.

Table of Contents

  1. What Affects Cometriq (Cabozantinib) Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Initial Review Timeline (1-5 Days)
  4. Additional Information Requests
  5. Decision Window and Outcomes
  6. Appeal Process and Fast-Track Options
  7. Timeline Visual Summary
  8. Time-Saving Tips
  9. Common Denial Reasons & Solutions
  10. Frequently Asked Questions

What Affects Cometriq (Cabozantinib) Approval Timing

Several factors determine how quickly Cigna processes your Cometriq prior authorization in Washington:

Washington State Requirements Under Washington's prior authorization law (effective 2024), Cigna must decide within:

  • Standard electronic PA: 3 calendar days
  • Expedited PA: 1 calendar day for urgent cases
  • Incomplete requests: Must request missing info within 1 calendar day

Documentation Completeness Cigna requires specific evidence for Cometriq, including:

  • Pathology confirming medullary thyroid carcinoma (MTC)
  • Disease staging and progression documentation
  • Prior therapy history and failures
  • RET mutation status (if applicable for targeted therapy)

Submission Method

  • Electronic PA (CoverMyMeds, Cigna portal): Fastest processing
  • Fax submissions: May take longer and risk delays
  • Phone requests: Generally not recommended for specialty drugs
Note: Express Scripts manages most Cigna specialty drug PAs and reports that "nearly all coverage reviews are completed within two days" once complete information is received.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Medical Records

  • Pathology report explicitly stating "medullary thyroid carcinoma"
  • Most recent oncology note (within 30-90 days)
  • Staging documentation (AJCC stage, metastatic sites)
  • Recent imaging reports (CT, MRI, or PET scans)

Treatment History

  • Prior systemic therapies with dates and outcomes
  • Surgical history (thyroidectomy, lymph node dissection)
  • Radiation therapy records if applicable
  • Documentation of treatment failures or intolerances

Laboratory Results

  • Calcitonin and CEA levels with trends
  • Baseline labs (CBC, CMP, liver function)
  • RET mutation testing results (if targeting RET pathway)

Insurance Verification

  • Confirm Cometriq requires PA through Cigna member services
  • Verify Accredo or designated specialty pharmacy requirement
  • Check formulary tier and quantity limits

Key Verification Steps

Call Cigna member services at the number on your insurance card to confirm:

  1. Prior authorization requirements for Cometriq
  2. Preferred specialty pharmacy (typically Accredo for Cigna)
  3. Any step therapy requirements
  4. Current formulary status and tier

Initial Review Timeline (1-5 Days)

Washington State Statutory Requirements

For Washington-regulated Cigna plans, the timeline is legally mandated:

Request Type Decision Deadline Real-World Timing
Standard Electronic PA 3 calendar days 1-3 business days
Expedited/Urgent PA 1 calendar day Within 24 hours
Incomplete Request Response 1 calendar day Same day notification

What Reviewers Check First

Cigna's medical reviewers evaluate:

  1. Diagnosis Confirmation
    • Pathology showing medullary thyroid carcinoma
    • Disease stage (locally advanced, unresectable, or metastatic)
    • ICD-10 coding accuracy
  2. FDA Indication Alignment
    • Cometriq is FDA-approved for progressive, metastatic MTC
    • Not interchangeable with Cabometyx tablets for other cancers
  3. Clinical Necessity
    • Disease progression documentation
    • Prior treatment failures or contraindications
    • Performance status and life expectancy
Tip: Electronic submissions through CoverMyMeds or Cigna's ExpressPAth system often receive same-day or next-day decisions when criteria are clearly met.

Additional Information Requests

If Cigna needs more documentation, they must request it within 1 calendar day under Washington law. Common requests include:

Frequently Missing Documents

  • Genetic testing results: RET mutation status for targeted therapy decisions
  • Progression evidence: Recent imaging showing disease advancement
  • Prior therapy details: Specific dates, doses, and discontinuation reasons
  • Contraindication documentation: Why formulary alternatives aren't appropriate

How to Respond Quickly

  • Same-day response: Keeps your case moving without delay
  • Electronic submission: Upload documents via Cigna provider portal
  • Complete package: Include all requested items in one submission

The clock effectively restarts when complete information is received, potentially adding 2-3 days to your timeline if responses are delayed.

Decision Window and Outcomes

Typical Approval Scenarios

Best Case (1-2 days)

  • Complete electronic PA with clear MTC diagnosis
  • All criteria met on first submission
  • No missing documentation

Standard Case (2-5 days)

  • Electronic PA with minor clarifications needed
  • Quick response to information requests
  • Straightforward medical necessity case

Complex Case (5-7 days)

  • Off-label use requiring additional evidence
  • Multiple prior therapy documentation needed
  • Peer-to-peer review required

Reading Your Approval Letter

Approved PAs typically include:

  • Approval duration: Usually 6-12 months for Cometriq
  • Quantity limits: Based on prescribed dose and frequency
  • Pharmacy restrictions: Often limited to Accredo or specialty network
  • Renewal requirements: Clinical response documentation needed

Appeal Process and Fast-Track Options

Internal Appeal Timeline (Cigna)

If your initial PA is denied, Washington law provides strong appeal rights:

Appeal Level Filing Deadline Decision Timeline Expedited Option
First Internal Appeal 180 days from denial 30 days standard 72 hours if urgent
Second Internal Appeal Per denial letter 30 days standard 72 hours if urgent
External Review (IRO) 180 days from final denial 30 days standard 72 hours if urgent

Expedited Appeal Criteria

Mark your appeal as expedited/urgent when delay would:

  • Seriously jeopardize life or health
  • Impair ability to regain maximum function
  • Risk irreversible progression of metastatic disease

External Review Success Rate

Washington's Independent Review Organization (IRO) process has approximately 82% overturn rate for specialty medication cases, making it a powerful option for complex denials.

Filing Your Appeal

Required Documents:

  • Original denial letter
  • Complete medical records supporting medical necessity
  • Prescriber letter explaining urgency and clinical rationale
  • NCCN guidelines or peer-reviewed literature supporting use

Where to Submit:

  • Cigna appeals department (address in denial letter)
  • Washington Office of the Insurance Commissioner for external review
  • Member portal for electronic submissions

Timeline Visual Summary

Day 0: Submit Electronic PA
↓
Days 1-3: Cigna Review (WA law: 3 days max)
↓
Day 3: Decision or Info Request
↓
Days 4-5: Respond to Info Request (if needed)
↓
Day 5-7: Final Decision
↓
If Denied: Appeal (180 days to file)
↓
Appeal Decision: 30 days (72 hours if urgent)
↓
External Review: 30 days (72 hours if urgent)

Time-Saving Tips

Maximize Approval Speed

  1. Use Electronic Submission
    • CoverMyMeds integration with Express Scripts
    • Cigna provider portal direct submission
    • EHR-integrated ePA tools
  2. Submit Complete Packages
    • All required documents in first submission
    • Clear, legible medical records
    • Specific diagnosis and staging information
  3. Leverage Specialty Pharmacy Coordination
    • Enroll with Accredo before PA approval
    • Coordinate prescription routing to avoid retail pharmacy delays
    • Set up patient assistance programs proactively
  4. Request Expedited Review When Appropriate
    • Document clinical urgency clearly
    • Provide prescriber attestation of risk from delay
    • Reference specific medical necessity criteria
From Our Advocates: In our experience helping patients navigate Cometriq approvals, the most successful cases involve oncology practices that maintain template letters with NCCN guideline references and submit complete documentation packages electronically. This composite approach typically results in approvals within 1-3 business days rather than the full statutory timeline.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Incorrect formulation Confirm Cometriq capsules vs Cabometyx tablets Prescription specifying capsule formulation
Missing MTC diagnosis Submit pathology report Pathology explicitly stating medullary thyroid carcinoma
Inadequate staging Provide disease progression evidence Recent imaging showing metastatic or progressive disease
Step therapy not met Document prior therapy failures Treatment records with dates, responses, toxicities
Off-label use Provide guideline support NCCN guidelines, peer-reviewed literature

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Cometriq in Washington? A: Electronic PAs are decided within 3 calendar days by Washington law, typically 1-3 business days in practice. Expedited requests get 24-hour decisions.

Q: What if Cometriq is not on my Cigna formulary? A: Request a formulary exception with clinical justification. Include evidence that formulary alternatives are inappropriate or contraindicated.

Q: Can I get an expedited appeal if my PA is denied? A: Yes, if delay would seriously jeopardize your health. Expedited appeals must be decided within 72 hours in Washington.

Q: Does step therapy apply if I've tried other treatments outside Washington? A: Yes, documented treatment failures from other states count toward step therapy requirements when properly documented.

Q: What's the success rate for Cometriq appeals? A: Washington's external review process has approximately 82% overturn rate for specialty medications when proper evidence is provided.

Q: How do I contact Washington's insurance regulator for help? A: Call the Washington Office of the Insurance Commissioner at 1-800-562-6900 for consumer advocacy assistance.

Q: What if my plan is Medicare through Cigna? A: Medicare plans follow federal appeal timelines (7 days standard, 72 hours expedited) rather than Washington state timelines.

When to Contact Counterforce Health

If you're facing complex denials or need help building a strong appeal case, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies specific policy criteria, and helps draft point-by-point rebuttals with the right clinical evidence and procedural requirements for your specific situation.

For patients dealing with specialty oncology drugs like Cometriq, having expert guidance can significantly improve approval odds and reduce the stress of navigating complex insurance processes. Counterforce Health understands payer-specific workflows and can help ensure your case includes all necessary documentation and meets exact procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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