By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Aetna CVS Health in Virginia: PA Requirements, Appeal Process & Forms

Answer Box: Getting Cabometyx Covered by Aetna CVS Health in Virginia

Key Challenge: Cabometyx (cabozantinib) is excluded from Aetna's 2024 Advanced Control formulary, meaning standard coverage is denied. However, Virginia patients can pursue a formulary exception through Aetna's medical necessity process.

Fastest Path to Approval:

  1. Request formulary exception through your oncologist (not standard prior authorization)
  2. Submit comprehensive medical necessity documentation showing why formulary alternatives failed or aren't appropriate
  3. Use Virginia's external review process if initially denied—Virginia offers expedited cancer treatment appeals

First Step Today: Contact your oncologist's office to initiate a formulary exception request and gather documentation of prior VEGFR-targeted therapy failures for thyroid cancer or sorafenib failure for hepatocellular carcinoma.

Table of Contents

Plan Types & Network Requirements

Your Aetna plan type significantly impacts how you access Cabometyx coverage in Virginia:

HMO Plans

  • Referral required from primary care physician to see oncologist
  • Referrals valid for 90 days from entry; first visit must occur within this window
  • In-network only coverage—out-of-network oncology care typically not covered
  • Specialty drug coverage requires proper referral chain

PPO Plans

  • No referral required for in-network oncologists
  • Out-of-network visits covered at reduced benefit levels
  • Greater flexibility in choosing specialists and pharmacies

EPO Plans

  • No referral required but strictly in-network only
  • Out-of-network care not covered except emergencies
  • Limited to in-network specialty pharmacies for Cabometyx
Note: All Aetna plans require prior authorization or formulary exceptions for specialty oncology medications, regardless of plan type.

Formulary Status & Coverage Reality

Current Coverage Status

Cabometyx is excluded from Aetna's 2024 Advanced Control formulary, placing it alongside other tyrosine kinase inhibitors like pazopanib, sorafenib, and sunitinib on the exclusion list.

What This Means for Patients

Coverage Scenario Reality Next Steps
Standard formulary coverage Not available Must pursue formulary exception
Prior authorization Not applicable (drug excluded) Exception process required instead
Step therapy Not applicable Must document alternative failures

Alternative Medications on Formulary

Your oncologist may need to demonstrate why these covered alternatives aren't appropriate:

  • Lenvatinib/pembrolizumab combinations
  • Nivolumab-based regimens
  • Sunitinib
  • Sorafenib (for hepatocellular carcinoma)

Medical Necessity & Exception Process

FDA-Approved Indications Aetna Covers

According to Aetna's medical policy, Cabometyx receives 12-month authorizations for:

Renal Cell Carcinoma:

  • Advanced RCC as monotherapy
  • First-line combination with nivolumab

Hepatocellular Carcinoma:

  • Adults previously treated with sorafenib

Differentiated Thyroid Cancer:

  • Locally advanced/metastatic disease
  • Progression after VEGFR-targeted therapy
  • Radioactive iodine-refractory or ineligible
  • Age 12+ years

Required Documentation for Exception

Clinical Evidence Needed:

  • Diagnosis with ICD-10 codes
  • Disease staging and progression documentation
  • Prior therapy records showing:
    • Specific medications tried
    • Duration of treatment
    • Reason for discontinuation (progression, intolerance)
  • Current imaging demonstrating disease status
  • Treatment goals and expected outcomes

For Thyroid Cancer Specifically:

  • Documentation of VEGFR-targeted therapy failure
  • Proof of radioactive iodine ineligibility/refractoriness
  • Age verification (≥12 years)

Clinician Corner: Medical Necessity Letter Checklist

✅ Problem Statement: Clear diagnosis with staging ✅ Prior Treatments: Specific agents, dates, outcomes
✅ Clinical Rationale: Why Cabometyx is uniquely appropriate ✅ Guideline Citations: NCCN, FDA labeling references ✅ Dosing Plan: Specific strength and administration ✅ Monitoring Plan: How response will be assessed

CVS Specialty Pharmacy Setup

Since Aetna uses CVS Caremark for specialty medications, your prescription will likely route through CVS Specialty Pharmacy.

Enrollment Process

Provider Requirements:

  1. Complete CVS Specialty Oral Oncology Enrollment Form
  2. Include front/back copy of Aetna insurance card
  3. Provide handwritten signature (stamps not accepted)
  4. Submit via fax or ePrescribe

Patient Information Needed:

  • Full legal name, DOB, address, phone
  • Primary language preference
  • Last four digits of SSN
  • Parent/guardian info if under 18

Timeline Expectations:

  • Insurance verification: ~1 week
  • CareTeam contact after approval
  • Financial assistance evaluation included

Appeal Process in Virginia

Aetna Internal Appeals

Deadlines: 60-65 calendar days from denial notice

Submission Options:

  • Fax: 1-724-741-4953 (standard), 1-724-741-4958 (expedited)
  • Phone (expedited only): 1-888-267-2637
  • Mail: Aetna Medicare Appeals, PO Box 14067, Lexington, KY 40512

Required Documentation:

  • Member name and Aetna ID
  • Detailed reason for appeal
  • All supporting medical records
  • Physician letter of medical necessity

Virginia External Review Process

If Aetna denies your appeal, Virginia's Bureau of Insurance offers independent external review:

Key Advantages:

  • 120 days to file after final internal denial
  • 45 days for standard review, 72 hours for expedited
  • Special provision: Cancer treatment denials can bypass internal appeals for expedited external review
  • Binding decision on the insurer

How to Access:

  1. Contact Virginia State Corporation Commission Bureau of Insurance: 1-877-310-6560
  2. Complete Form 216-A (External Review Request)
  3. Submit within 120 days of final internal denial
From Our Advocates: "We've seen Virginia patients successfully overturn Cabometyx denials by emphasizing the state's expedited cancer provision. One patient with thyroid cancer had their external review completed in under a week by documenting progression after lenvatinib and demonstrating Cabometyx as the only remaining FDA-approved option. The key was having comprehensive imaging and prior therapy records ready."

Cost-Share Considerations

Typical Patient Costs

If Approved:

  • Specialty tier copay/coinsurance applies
  • Annual deductible may need to be met first
  • Out-of-pocket maximum provides yearly cap

Financial Assistance Options:

  • Manufacturer support: Check Exelixis patient assistance programs
  • Copay cards: May reduce monthly costs significantly
  • Foundation grants: Cancer-specific organizations in Virginia

Price Context

Exelixis reported a 2.8% U.S. WAC increase effective January 1, 2025, reflecting ongoing specialty pricing pressures.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Not on formulary" Request formulary exception with medical necessity documentation
"Off-label use" Provide FDA labeling or recognized compendia support
"Lack of documentation" Submit complete medical records, imaging, prior therapy details
"Alternative available" Document specific failures/contraindications to formulary options
"Wrong formulation" Ensure prescription specifies Cabometyx tablets, not capsules

FAQ

How long does Aetna's formulary exception process take in Virginia? Standard decisions typically take 30-45 days. Expedited reviews for urgent medical situations are decided within 72 hours.

What if Cabometyx is completely excluded from my plan? You can still request a formulary exception. Virginia law requires insurers to have an exception process even for excluded drugs.

Can I request an expedited appeal? Yes, if your doctor certifies that waiting would seriously jeopardize your health. Virginia offers expedited external review specifically for cancer treatments.

Does step therapy apply if I've tried similar drugs outside Virginia? Yes, prior therapy records from any location count toward demonstrating medical necessity, as long as they're properly documented.

What happens if both internal and external appeals fail? You retain the right to pursue legal action separately, though this is rare. Consider consulting with healthcare attorneys familiar with insurance law.

How does this process differ for Medicare Advantage vs. commercial Aetna plans? Medicare Advantage has federal appeal rights in addition to Virginia state protections. Timelines may be slightly different, but the basic exception process remains similar.

When Coverage Gets Complex: Counterforce Health Can Help

Navigating Cabometyx coverage with Aetna can be challenging, especially when dealing with formulary exclusions and medical necessity requirements. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing your specific denial reasons and crafting point-by-point rebuttals aligned to Aetna's own coverage policies.

The platform helps patients and clinicians gather the right clinical evidence—from FDA labeling to peer-reviewed studies—and weaves them into appeals that meet Virginia's procedural requirements while tracking critical deadlines. For complex cases like Cabometyx formulary exceptions, having expert support can make the difference between approval and denial.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For assistance with Virginia insurance issues, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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