By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Aetna CVS Health in California: Complete Prior Authorization Guide

Quick Answer: Getting Cabometyx Covered by Aetna CVS Health in California

Cabometyx (cabozantinib) requires prior authorization from Aetna CVS Health for FDA-approved cancer indications. Your oncologist must submit clinical documentation including diagnosis codes (ICD-10), pathology reports, prior therapy failures, and recent imaging. California law requires decisions within 72 hours for standard requests, 24 hours for urgent cases. If denied, you can appeal internally then request California's free Independent Medical Review (IMR), which overturns 55-68% of specialty drug denials.

First step today: Contact your oncologist to gather medical records and verify your Aetna plan's formulary status for Cabometyx at 1-800-282-2881.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Required Documentation
  4. Costs and Patient Assistance
  5. Common Denial Reasons
  6. Appeals Process in California
  7. Renewal and Reauthorization
  8. Specialty Pharmacy Requirements
  9. Frequently Asked Questions
  10. When to Contact California Regulators

Coverage Basics

Is Cabometyx Covered by Aetna CVS Health?

Cabometyx is covered for FDA-approved indications but requires prior authorization on most Aetna plans. Some 2024-2026 formularies list it as excluded, requiring both prior authorization and a formulary exception.

Covered Indications:

  • Advanced renal cell carcinoma (RCC) - alone or with nivolumab
  • Hepatocellular carcinoma (HCC) after sorafenib failure
  • Radioactive iodine-refractory differentiated thyroid cancer (DTC) age ≥12
  • RET-rearranged non-small cell lung cancer (NSCLC) with genetic documentation

Which Aetna Plans Apply?

This guidance applies to Aetna CVS Health plans in California including:

  • Commercial employer plans
  • Individual/family plans (Exchange and off-Exchange)
  • Medicare Advantage plans
  • Medicaid managed care plans
Important: Cabometyx tablets and Cometriq capsules are NOT interchangeable. Aetna will deny authorizations that confuse these formulations.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic Staff)
    • Call Aetna member services: 1-800-282-2881
    • Confirm formulary tier and copay/coinsurance
    • Timeline: 5-10 minutes
  2. Gather Documentation (Oncologist)
    • Medical records, pathology reports, imaging (within 6 months)
    • Prior therapy records with dates and outcomes
    • Timeline: 1-2 business days
  3. Submit Prior Authorization (Clinic)
    • Preferred: Availity provider portal or Novologix
    • Phone: 1-866-814-5506 (specialty PA unit)
    • Fax: 1-866-249-6155
    • Timeline: Submit ≥2 weeks before planned therapy
  4. Decision Timeline (California Law)
    • Standard requests: 72 hours
    • Urgent/expedited: 24 hours
    • Auto-approved if Aetna doesn't respond timely
  5. If Approved (Pharmacy)
    • CVS Specialty or network pharmacy dispenses
    • Enroll in EASE Co-Pay Program for $0 copay

Required Documentation

Medical Necessity Letter Checklist

Your oncologist must include:

Clinical Information:

  • ✅ Diagnosis with ICD-10 codes (C64.1/C64.2 for RCC, C22.0 for HCC, C73 for DTC)
  • ✅ Pathology reports confirming cancer type and staging
  • ✅ Recent imaging (CT/MRI within 6 months) with RECIST measurements
  • ✅ Performance status and weight for dosing calculations

Prior Therapy Documentation:

  • ✅ Previous treatments tried (drugs, dates, durations)
  • ✅ Response/progression documentation
  • ✅ Reasons for discontinuation (progression, toxicity, intolerance)
  • ✅ Why alternatives are unsuitable

Safety Information:

  • ✅ Current medications list (drug interaction screening)
  • ✅ Liver and kidney function tests
  • ✅ Blood pressure monitoring plan
Clinician Corner: Reference FDA labeling and NCCN guidelines in your letter. For RET-rearranged NSCLC, genetic testing documentation is mandatory for approval.

Costs and Patient Assistance

Understanding Your Costs

Plan Type Typical Coverage Patient Cost
Commercial Specialty tier (Tier 4-5) 25-40% coinsurance
Medicare Advantage Specialty tier $0-$150+ copay
Medicaid Covered with PA $0-$3 copay

EASE Co-Pay Program (Exelixis)

Eligible patients with commercial insurance (including Aetna) can reduce costs to $0 per month:

  • Enrollment: Doctor initiates form, patient completes authorization
  • Contact: 1-844-900-EASE or online at ease.us
  • Fax: 1-844-901-3273
  • Limits: Annual/transaction caps apply; not for government plans

Additional Support:

  • BE CONNECTED program: Free educational resources for U.S. residents
  • Patient Assistance Program: Free medication for uninsured/underinsured patients

Common Denial Reasons

Denial Reason How to Overturn Required Evidence
Wrong formulation Clarify Cabometyx tablets vs. Cometriq capsules FDA label excerpts, indication-specific rationale
Insufficient prior therapy Document step therapy compliance Treatment records with dates, outcomes, imaging
Missing diagnosis codes Submit complete pathology ICD-10 codes, staging, genetic testing (if applicable)
Drug interactions Address safety concerns Current medications review, monitoring plan
Non-formulary status Request formulary exception Medical necessity letter, guideline references

Scripts for Common Situations

Patient calling Aetna about denial:

"I'm calling about a prior authorization denial for Cabometyx for [cancer type]. My member ID is [ID]. Can you tell me the specific denial reason and what additional documentation is needed? I'd like to request an expedited appeal since this is for cancer treatment."

Clinic requesting peer-to-peer review:

"I'm requesting a peer-to-peer review for [patient name], member ID [ID], for Cabometyx denial. This is for FDA-approved [indication]. I have additional clinical documentation that addresses the denial rationale. When is the earliest available time for the review?"

Appeals Process in California

Internal Appeals with Aetna

Timeline: Must file within 180 days of denial notice

How to Submit:

  • Online: Aetna member portal
  • Phone: Member services at number on insurance card
  • Mail: Address provided in denial letter

Required Documents:

  • Denial letter
  • Additional medical records
  • Updated physician letter addressing denial reasons

California Independent Medical Review (IMR)

If Aetna upholds the denial, California residents can request a free, binding external review.

Eligibility:

  • Exhausted Aetna's internal appeals
  • Denial based on medical necessity, experimental/investigational, or coverage disputes
  • File within 6 months of final internal denial

How to Apply:

Timeline:

  • Standard IMR: 30-45 days
  • Expedited IMR: 7 days (urgent cases)
  • Implementation: 5 business days after approval

Success Rates: 55-68% of specialty drug denials are overturned by IMR

From our advocates: We've seen California patients successfully overturn Aetna denials for specialty cancer drugs by submitting comprehensive medical records and peer-reviewed literature during IMR. The key is thorough documentation of why the medication is medically necessary and appropriate for the specific cancer type and stage.

Renewal and Reauthorization

When to Renew

Cabometyx authorizations are typically approved for 12 months. Start the renewal process 30-60 days before expiration.

Renewal Requirements:

  • No disease progression on current therapy
  • Acceptable toxicity profile
  • Continued medical necessity

Documentation for Renewal:

  • Recent imaging showing stable disease or response
  • Updated lab values
  • Physician assessment of benefit/risk

What Triggers Reauthorization

  • Change in dosing or administration schedule
  • New indication or off-label use
  • Switching between Cabometyx formulations
  • Plan changes or new insurance year

Specialty Pharmacy Requirements

CVS Caremark Network

Most Aetna plans require Cabometyx to be dispensed through specialty pharmacies:

In-Network Options:

  • CVS Specialty Pharmacy
  • Accredo (CVS Caremark network)
  • Other contracted specialty pharmacies

Benefits of Specialty Pharmacy:

  • Clinical monitoring and support
  • Insurance coordination
  • Patient assistance program enrollment
  • Adherence tracking

What to Expect:

  • Initial consultation call
  • Monthly refill coordination
  • Side effect monitoring
  • Insurance benefit verification

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in California? Standard requests: 72 hours maximum by California law. Urgent requests: 24 hours. Auto-approval if Aetna doesn't respond within these timeframes.

What if Cabometyx is not on my formulary? Request a formulary exception along with prior authorization. Provide medical necessity documentation explaining why formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, for urgent medical situations. Your oncologist must certify that delays could seriously jeopardize your health. Expedited appeals are decided within 72 hours.

Does step therapy apply if I failed treatments in another state? Yes, prior therapy documentation from any location counts toward step therapy requirements. Ensure records include dates, doses, and reasons for discontinuation.

What happens if my appeal is denied? You can request California's Independent Medical Review (IMR) through the DMHC. This is a free, binding external review with high success rates for specialty drugs.

How much will Cabometyx cost with Aetna? Costs vary by plan. Commercial plans typically have 25-40% coinsurance for specialty drugs. The EASE Co-Pay Program can reduce costs to $0/month for eligible patients.

Can I use GoodRx or other discount programs? Discount programs typically don't work with insurance. Instead, enroll in the manufacturer's EASE program for maximum savings with your Aetna coverage.

What if my doctor's office doesn't know how to submit the prior authorization? Contact Aetna's provider services at 1-866-814-5506. They can guide the office through the submission process and provide necessary forms.

When to Contact California Regulators

Department of Managed Health Care (DMHC)

Contact the DMHC if:

  • Aetna violates appeal timelines
  • You need help filing an IMR
  • You have concerns about care delays

DMHC Help Center:

  • Phone: 888-466-2219
  • Website: healthhelp.ca.gov
  • Services available in multiple languages

California Department of Insurance (CDI)

For certain PPO or indemnity plans regulated by CDI:

  • Consumer Hotline: 800-927-4357
  • External review process similar to IMR

Getting Additional Help

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling appropriate citations from FDA labeling, peer-reviewed studies, and specialty guidelines while ensuring all required clinical facts and procedural requirements are met.

For complex cases, consider contacting:

  • Health Consumer Alliance (California nonprofit)
  • Legal aid organizations
  • Patient advocacy groups for your specific cancer type

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions are made by your health plan based on your specific policy and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For official California insurance regulations and consumer protections, visit the Department of Managed Health Care at healthhelp.ca.gov.

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