By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Cigna in New Jersey: Complete Prior Authorization and Appeals Guide

Quick Answer: Cabometyx (cabozantinib) requires prior authorization from Cigna in New Jersey, typically approved within 72 hours with complete documentation. Key requirements: FDA-approved diagnosis (RCC, HCC, or other labeled indications), documented prior therapy failures, and oncologist prescription. Submit via CoverMyMeds or Cigna provider portal. If denied, New Jersey's Independent Health Care Appeals Program (IHCAP) provides binding external review through Maximus Federal Services. First step: gather diagnosis documentation, prior treatment records, and request the Cigna Cabometyx PA form.

Table of Contents

What This Guide Covers

This guide helps patients, caregivers, and clinicians navigate Cigna's prior authorization process for Cabometyx (cabozantinib) in New Jersey. You'll learn exactly what documents to gather, how to submit requests, and what to do if you're denied coverage.

Cabometyx is an oral targeted therapy approved by the FDA for advanced renal cell carcinoma (RCC), hepatocellular carcinoma (HCC) after sorafenib treatment, and differentiated thyroid carcinoma that's radioactive iodine-refractory. It's manufactured by Exelixis and typically costs in the specialty drug price range, making insurance coverage essential for most patients.

Who this helps:

  • Patients prescribed Cabometyx by their oncologist
  • Family members managing insurance for a cancer patient
  • Clinic staff handling prior authorizations
  • Anyone facing a Cigna denial for this medication

Before You Start: Verify Your Coverage

Check Your Plan Type

Cigna manages Cabometyx through different pathways depending on your plan:

  • Commercial plans: Express Scripts specialty pharmacy (usually Accredo)
  • Medicare Advantage: May be covered under Part B (medical) or Part D (pharmacy)
  • Medicaid managed care: State-specific formulary rules apply

Confirm Formulary Status

Cabometyx is typically placed on Cigna's specialty tier, requiring prior authorization regardless of your specific plan. Check your plan's formulary at Cigna.com or call the member services number on your insurance card.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Cigna plans Cigna PA Policy
Specialty Pharmacy Must use Accredo (Express Scripts) Cigna Specialty Pharmacy Guide
Age Requirement ≥18 years (RCC/HCC), ≥12 years (thyroid cancer) FDA labeling
Prescriber Oncologist or in consultation with oncologist Cigna PA policy
Duration Up to 1 year approval Cigna PA policy

Gather What You Need

Before submitting your prior authorization request, collect these essential documents:

Medical Documentation

  • Diagnosis confirmation: Pathology report, imaging studies showing advanced/metastatic disease
  • ICD-10 codes: Your clinic will include these, but common ones include C78.00 (metastatic RCC), C22.0 (HCC)
  • Prior therapy records: Complete list of previous treatments with dates, doses, and outcomes
  • Current clinical status: Recent labs, performance status, imaging showing disease progression

Insurance Information

  • Insurance card (front and back copies)
  • Patient ID and group numbers
  • Prescriber NPI and clinic information

Prescription Details

  • Specify "Cabometyx tablets" (not generic cabozantinib capsules)
  • Prescribed dose (typically 60mg daily for monotherapy)
  • Duration of therapy
Tip: The most common reason for delays is incomplete prior therapy documentation. Make sure you have specific dates, drug names, and reasons for discontinuation (progression, intolerance, etc.).

Submit the Request

Step-by-Step: Fastest Path to Approval

  1. Download the PA form from Cigna's oncology PA policy
  2. Submit electronically via:
  3. Include all supporting documents in the initial submission:
    • Medical necessity letter from oncologist
    • Pathology/imaging reports
    • Prior treatment timeline
    • Current labs and clinical notes
  4. Request expedited review if treatment delay could harm the patient (decision within 24 hours)
  5. Follow up within 48-72 hours to confirm receipt and check status

Medical Necessity Letter Checklist

Your oncologist's letter should address:

  • Specific FDA-approved indication being treated
  • Prior therapies tried and failed (with dates and reasons for discontinuation)
  • Clinical rationale for Cabometyx based on NCCN guidelines or FDA labeling
  • Treatment goals and monitoring plan
  • Contraindications to alternative therapies (if applicable)

Follow-Up and Timelines

Expected Timelines

  • Standard review: Up to 72 hours
  • Expedited review: 24 hours (requires medical urgency documentation)
  • Accredo contact: 24-48 hours after approval
  • First medication delivery: 3-5 business days after patient coordination

When to Call Cigna

Call 1-800-882-4462 if:

  • No decision after 72 hours (standard) or 24 hours (expedited)
  • You receive a request for additional information
  • The status shows "pending" without explanation

Sample Phone Script

"Hi, I'm calling to check the status of a prior authorization request for Cabometyx for [patient name], DOB [date], member ID [number]. The request was submitted on [date] via [portal name]. Can you tell me the current status and if any additional information is needed?"

If You're Asked for More Information

Common requests and how to respond:

"Need more details on prior therapies"

Provide a detailed timeline including:

  • Drug names and doses
  • Start and stop dates
  • Reason for discontinuation (progression, toxicity, intolerance)
  • Imaging or lab results showing progression

"Clarify medical necessity"

Submit additional documentation:

  • Recent imaging showing disease progression
  • NCCN guideline references supporting the treatment choice
  • Peer-reviewed literature (if off-label use)
  • Patient-specific factors making alternatives inappropriate

If Denied: Appeals Process

Common Denial Reasons and Solutions

Denial Reason How to Fix It
"Not medically necessary" Submit NCCN guidelines, FDA labeling, peer-reviewed studies
"Insufficient prior therapy" Provide complete treatment history with dates and outcomes
"Wrong formulation requested" Ensure prescription specifies "Cabometyx tablets"
"Off-label use" Include specialty guidelines and published literature

Cigna Internal Appeals

  1. First-level appeal: Submit within 180 days via Cigna member portal or written request
  2. Second-level appeal: Available if first appeal is denied
  3. Peer-to-peer review: Request discussion between your oncologist and Cigna medical director

Sample Appeal Letter Points

  • Reference specific Cigna policy criteria that support coverage
  • Include updated clinical information
  • Cite relevant medical literature
  • Address the specific denial reason with evidence

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps identify the specific denial basis and drafts point-by-point responses aligned to each payer's own rules.

New Jersey External Review Process

If Cigna denies your internal appeals, New Jersey offers excellent protection through the Independent Health Care Appeals Program (IHCAP).

How IHCAP Works

  • Who handles it: Maximus Federal Services (contracted by New Jersey)
  • Timeline to file: 4 months (180 days) after final internal denial
  • Cost to you: Nothing - insurers pay all review costs
  • Decision timeline: 45 days for standard review, expedited available for urgent cases

IHCAP Process

  1. Complete internal appeals first (required before external review)
  2. Submit external appeal directly to Maximus Federal Services
  3. Preliminary review (5 business days to confirm eligibility)
  4. Full medical review by specialist physicians
  5. Binding decision - if approved, Cigna must provide coverage

Contact Information

From our advocates: "We've seen many New Jersey patients succeed with external review when they include a detailed letter from their oncologist explaining why the treatment is needed and addressing the insurer's specific denial reason. The independent medical reviewers consider this alongside published literature, and about half of external appeals nationwide favor consumers."

Costs and Savings Options

Manufacturer Support

  • EASE Program: Exelixis patient assistance for uninsured/underinsured patients
  • Commercial copay cards: May reduce out-of-pocket costs (check eligibility restrictions)

Foundation Grants

  • Patient Access Network (PAN) Foundation
  • HealthWell Foundation
  • Leukemia & Lymphoma Society (for applicable cancers)

State Programs

New Jersey residents may qualify for additional assistance through state pharmaceutical assistance programs.

Renewal and Re-Authorization

When to Start the Process

Begin renewal requests 30-45 days before your current authorization expires (typically after 11 months).

What to Include

  • Updated imaging or lab results
  • Clinical response assessment
  • Any changes in treatment plan
  • Continued medical necessity justification

Calendar reminder: Set alerts for 30 days before expiration to avoid treatment interruptions.

FAQ

How long does Cigna prior authorization take in New Jersey? Standard review is completed within 72 hours. Expedited review (for urgent cases) is completed within 24 hours.

What if Cabometyx is non-formulary on my plan? You can request a formulary exception with clinical justification. The appeals process described above also applies to formulary exceptions.

Can I request an expedited appeal? Yes, if treatment delay could seriously harm your health. Both internal and external appeals can be expedited with proper medical documentation.

Does step therapy apply if I've failed treatments outside New Jersey? Yes, prior therapies count regardless of where they were administered, as long as they're properly documented.

What's the difference between Cabometyx tablets and cabozantinib capsules? Cabometyx (tablets) and Cometriq (capsules) are different formulations with different FDA approvals. Make sure your prescription specifies the correct formulation.

Can my doctor request a peer-to-peer review? Yes, your oncologist can request to speak directly with a Cigna medical director during the appeals process.

Quick Reference Checklist

Before Submitting:

  • Confirm Cigna covers Cabometyx on your plan
  • Gather diagnosis documentation and ICD-10 codes
  • Collect complete prior therapy timeline
  • Download Cigna PA form
  • Ensure prescription specifies "Cabometyx tablets"

Submission:

  • Submit via CoverMyMeds or Cigna portal
  • Include medical necessity letter
  • Attach all supporting clinical documents
  • Request expedited review if urgent
  • Document submission date and reference number

Follow-Up:

  • Call within 72 hours to check status
  • Respond promptly to requests for additional information
  • Set calendar reminder for renewal (11 months)

If Denied:

  • Review specific denial reason
  • File internal appeal within 180 days
  • Consider peer-to-peer review
  • Prepare for external review if needed

For complex cases or persistent denials, consider working with Counterforce Health, which helps patients and clinicians create targeted appeals by analyzing payer policies and crafting evidence-backed responses that address specific denial reasons.

Sources & Further Reading

This guide is for informational purposes only and is not medical advice. Always consult with your healthcare provider about treatment decisions. For specific questions about your coverage, contact Cigna member services or consult with your clinic's insurance specialists.

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