By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Aetna CVS Health in Georgia: Complete PA Guide and Appeals Process

Answer Box: Cabometyx (cabozantinib) is excluded from Aetna CVS Health's 2024 formulary, requiring a formulary exception rather than standard prior authorization. In Georgia, you have 180 days to appeal internally and 60 days for external review through the Georgia Department of Insurance. First step today: Have your oncologist submit a comprehensive medical necessity letter with prior therapy documentation and FDA-approved diagnosis codes. If denied, Georgia's external review process is free and binding on insurers.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It
Formulary Status Excluded - requires exception Aetna Advanced Control formulary
Prior Authorization Formulary exception required Submit via Aetna provider portal
Step Therapy Must document alternative failures Include prior therapy records
Appeal Deadline 180 days (internal), 60 days (external) Georgia DOI regulations
External Review Free, binding process Georgia Department of Insurance

Understanding Aetna's Formulary Status

Cabometyx (cabozantinib) tablets are excluded from Aetna CVS Health's 2024 Advanced Control formulary for most commercial and exchange plans. This means you cannot use standard prior authorization—instead, you need a formulary exception.

Important: Don't confuse Cabometyx tablets with cabozantinib capsules (Cometriq). They have different NDC codes and indications, and billing errors cause automatic denials.

What This Means for You

  • Your oncologist must submit a comprehensive medical necessity letter
  • You'll need detailed documentation of prior therapy failures
  • The approval process may take longer than standard prior authorizations
  • If denied, Georgia's external review process offers a powerful appeal option

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who does it: You and your care team
Timeline: 1-2 days
What you need:

  • Insurance card and policy details
  • Complete medical records with cancer staging
  • Prior therapy history (drugs, dates, outcomes)
  • Recent imaging studies (CT, MRI with RECIST criteria)
  • Lab results (liver and kidney function)

2. Verify Your Diagnosis Code

Who does it: Your oncologist
Timeline: Same day
Required ICD-10 codes:

  • Renal Cell Carcinoma: C64.9 (unspecified), C64.1 (right kidney), C64.2 (left kidney)
  • Hepatocellular Carcinoma: C22.0 (must document prior sorafenib failure)
  • Differentiated Thyroid Cancer: C73 (must document radioactive iodine-refractory status)

3. Submit Formulary Exception Request

Who does it: Your oncologist's office
Timeline: Submit within 3-5 business days
How: Via Aetna provider portal or designated fax line
Include: Medical necessity letter addressing why formulary alternatives aren't appropriate

4. Track Your Request

Who does it: You or clinic staff
Timeline: Check status after 5-7 business days
Expected response: 30-45 days for standard review, 72 hours for expedited

5. Prepare for Potential Denial

Who does it: Your care team
Timeline: Immediately upon denial
Next steps: File internal appeal within 180 days, gather additional evidence

ICD-10 Codes and Documentation Requirements

Primary Diagnosis Codes

Your medical records must clearly document the specific cancer type and stage:

Renal Cell Carcinoma (RCC)

  • C64.9: Malignant neoplasm of kidney, unspecified
  • C64.1: Malignant neoplasm of right kidney
  • C64.2: Malignant neoplasm of left kidney

Hepatocellular Carcinoma (HCC)

  • C22.0: Liver, primary
  • Critical: Must document prior sorafenib failure and rationale for switch

Differentiated Thyroid Cancer (DTC)

  • C73: Malignant neoplasm of thyroid gland
  • Critical: Must document radioactive iodine-refractory status

Supporting Documentation Checklist

✓ Pathology report confirming diagnosis and cancer type
✓ Cancer staging and current disease status
✓ Recent imaging studies with RECIST criteria when applicable
✓ Prior therapy history with specific drugs, dates, and outcomes
✓ Clinical rationale for why formulary alternatives aren't appropriate
✓ Current lab results (liver and kidney function)
✓ Prescriber credentials and oncology certification

Clinician Corner: Your medical necessity letter should reference FDA labeling, NCCN guidelines, and specific clinical factors that make Cabometyx the most appropriate choice. Include dosing rationale and monitoring plan.

Product Coding: HCPCS, NDC, and Billing

HCPCS J-Code

J8999: Prescription drug, oral, chemotherapeutic, NOS

  • Cabometyx tablets don't have a unique, product-specific J-code
  • Always specify "Cabometyx (cabozantinib)" in claim notes
  • Bill by total milligrams, not tablet count

NDC Codes for Cabometyx Tablets

  • 15 mg tablets: 42388-023-46
  • 20 mg tablets: 42388-023-26
  • 40 mg tablets: 42388-023-36
  • 60 mg tablets: 42388-023-37

Billing Units

  • Pharmacy Benefit: Use NDC codes with quantity as number of tablets
  • Medical Benefit: Use J8999 with total milligrams
  • Example: 30-day supply of 60 mg = NDC 42388-023-37, quantity 30 (total 1,800 mg)
Note: Double-check you're using tablet NDCs, not capsule codes. This is the most common billing error that causes automatic denials.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Non-formulary drug Submit formulary exception with medical necessity Prior therapy failures, clinical rationale
Step therapy not met Document alternative drug failures/intolerance Therapy records, adverse event notes
Insufficient documentation Provide complete medical records Staging, imaging, lab results
Wrong formulation Clarify Cabometyx tablets vs capsules Prescription specifying tablet form
Experimental/investigational Reference FDA approval and guidelines FDA labeling, NCCN guidelines

Appeals Process in Georgia

Internal Appeals with Aetna

Timeline: Must file within 180 days of denial
Process: Submit via Aetna member portal or written request
Decision time: 30 days (standard) or 72 hours (expedited)
Required: Additional clinical evidence, peer-reviewed studies

External Review Through Georgia DOI

If your internal appeal is denied, Georgia offers a powerful external review process:

Eligibility: Medical necessity disputes, experimental/investigational denials
Deadline: 60 days from final internal denial
Cost: Free to consumers
Decision: Binding on Aetna CVS Health

How to Request:

  1. Contact Georgia Department of Insurance at 1-800-656-2298
  2. Request external review form via email: [email protected]
  3. Submit completed form with supporting documents
  4. Wait for Independent Review Organization (IRO) assignment

Timeline:

  • Standard review: 30 days
  • Expedited review: 72 hours (for urgent medical situations)
From our advocates: We've seen many Georgia patients successfully overturn Aetna denials for specialty cancer drugs through external review. The key is comprehensive documentation of medical necessity and clear evidence that formulary alternatives aren't clinically appropriate. While outcomes vary by case, the external review process provides an important safety net when internal appeals fail.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and ensuring all procedural requirements are met.

Costs and Patient Assistance

Manufacturer Support

Exelixis Patient Assistance Program

  • Financial assistance for eligible patients
  • Copay cards for commercially insured patients
  • Application available through oncology office

Foundation Grants

  • Patient Access Network Foundation
  • CancerCare Copay Assistance
  • Leukemia & Lymphoma Society

Georgia-Specific Resources

  • Georgia Cancer Info Link: Patient navigation services
  • American Cancer Society: Local financial assistance programs

When to Contact Georgia Insurance Regulators

Contact the Georgia Department of Insurance if:

  • Aetna doesn't respond to appeals within required timeframes
  • You believe the denial violates Georgia insurance law
  • You need help understanding your appeal rights

Georgia DOI Consumer Services: 1-800-656-2298
Online complaint form: Available on Georgia DOI website
What to include: Policy details, denial letters, timeline of communications

FAQ

How long does Aetna CVS Health prior authorization take in Georgia?
Standard formulary exceptions take 30-45 days. Expedited reviews (for urgent medical situations) are completed within 72 hours.

What if Cabometyx is completely non-formulary on my plan?
You can still request a formulary exception with strong medical necessity documentation. Georgia's external review process provides additional recourse if denied.

Can I request an expedited appeal if my cancer is progressing?
Yes. Both Aetna and Georgia's external review process offer expedited timelines (72 hours) for urgent medical situations where delay could cause serious harm.

Does step therapy apply if I failed similar drugs outside Georgia?
Yes, prior therapy failures from any state count toward step therapy requirements. Ensure your medical records clearly document these experiences.

What happens if the external review upholds Aetna's denial?
The external review decision is final for the administrative process. Further recourse would require legal action, though this is uncommon for FDA-approved cancer drugs with proper documentation.

Can Counterforce Health help with my Aetna appeal?
Yes, our platform specializes in turning insurance denials into targeted appeals by analyzing payer policies and drafting evidence-backed responses that meet specific procedural requirements.

Disclaimer: This information is for educational purposes and doesn't constitute medical or legal advice. Insurance policies and state regulations change frequently. Always verify current requirements with Aetna CVS Health and consult your healthcare team for medical decisions.

Sources & Further Reading

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