By Counterforce Health Team in Cabometyx (cabozantinib) —

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

Quick Answer: Cigna requires prior authorization for Cabometyx (cabozantinib tablets) with documentation of FDA-approved diagnosis, prior therapy failures, and medical necessity. Your oncologist submits through Cigna's portal or CoverMyMeds within 72 hours standard review. If denied, you have 180 days for internal appeal, then 4 months for New York State external review through DFS. Start by gathering your treatment history and having your doctor complete the PA form today.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Approval Criteria
  5. Costs and Copay Assistance
  6. Denials and Appeals
  7. Renewals and Reauthorization
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. New York External Appeal Rights

Coverage Basics

Is Cabometyx (cabozantinib) covered by Cigna?

Cigna covers Cabometyx tablets for FDA-approved indications with prior authorization. The medication requires step therapy documentation for hepatocellular carcinoma and proof of prior VEGF or immunotherapy for renal cell carcinoma in most cases.

Important: Only Cabometyx tablets are covered for these cancers. Cometriq capsules are a different formulation approved only for medullary thyroid cancer and cannot be substituted.

Which Cigna plans require prior authorization?

All Cigna commercial plans, Medicare Advantage, and most Medicaid managed care plans require prior authorization for Cabometyx. The medication is typically dispensed through Express Scripts specialty pharmacy or Accredo.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Complete treatment history with dates and outcomes
    • Recent imaging (CT/MRI within 3 months)
    • Pathology reports confirming diagnosis
    • ICD-10 codes and staging information
  2. Complete PA Form (Prescriber)
    • Submit via Cigna provider portal or CoverMyMeds
    • Include medical necessity letter with clinical rationale
    • Attach all supporting documentation
  3. Submit Request (Prescriber)
    • Standard review: online portal or fax
    • Expedited review: call Cigna directly for urgent cases
    • Track submission with confirmation number
  4. Await Decision (72 hours standard, 24 hours expedited)
    • Cigna reviews against coverage criteria
    • May request additional information
    • Decision communicated to prescriber and patient
  5. If Approved (Patient/Clinic)
    • Coordinate with Accredo or designated specialty pharmacy
    • Enroll in copay assistance programs
    • Schedule delivery and monitoring

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Cigna formulary Cigna PA List
Step Therapy (HCC) Must fail sorafenib first Coverage policy Cigna Coverage Policy
Specialty Pharmacy Accredo or Express Scripts Member portal Cigna Specialty Pharmacy
Formulary Tier Specialty tier (varies by plan) Plan documents Plan-specific formulary

Timing and Deadlines

How long does Cigna prior authorization take?

  • Standard review: 72 hours after complete submission
  • Expedited review: 24 hours for urgent medical needs
  • Additional information requests: May extend timeline by 14 days

What if it's urgent?

For expedited review, your oncologist must attest that waiting for standard review would seriously jeopardize your health. Contact Cigna directly at the provider services number on your insurance card.

Approval Criteria

What documentation does Cigna require?

For Renal Cell Carcinoma:

  • Advanced or metastatic RCC diagnosis
  • Prior VEGF-targeted therapy or immunotherapy (with dates and outcomes)
  • Recent imaging showing disease progression
  • Medical necessity letter explaining treatment rationale

For Hepatocellular Carcinoma:

  • Advanced HCC diagnosis with staging
  • Documentation of sorafenib treatment failure or intolerance
  • Child-Pugh class and ECOG performance status
  • Recent imaging and laboratory values

For Radioiodine-Refractory Differentiated Thyroid Cancer:

  • RAI-refractory DTC diagnosis
  • Prior VEGFR-targeted therapy failure
  • Age ≥12 years with appropriate weight-based dosing
  • Thyroglobulin levels and imaging progression
Clinician Corner: Your medical necessity letter should include: specific diagnosis with ICD-10 codes, complete prior therapy history with dates and reasons for discontinuation, current disease status with recent imaging, treatment goals, and citations to relevant clinical guidelines or FDA labeling. Counterforce Health specializes in creating evidence-backed appeals that align with payer-specific criteria and can help draft targeted medical necessity documentation.

Costs and Copay Assistance

What will I pay out-of-pocket?

Cigna specialty tier medications typically have:

  • Coinsurance: 20-33% of drug cost
  • Copay: $150-$500 per fill (plan-dependent)
  • Deductible: May apply before coverage begins

Available Assistance Programs

Manufacturer Copay Program:

  • Exelixis CABOMETYX Copay Program may reduce costs to $0
  • Available for commercially insured patients
  • Not available for Medicare, Medicaid, or uninsured patients

Foundation Grants:

  • Patient Access Network Foundation
  • CancerCare Co-Payment Assistance Foundation
  • Good Days (formerly Chronic Disease Fund)

Contact Accredo's financial counselors to screen for all available programs.

Denials and Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient prior therapy Document failed treatments Treatment dates, outcomes, intolerance notes
Missing imaging Submit recent scans CT/MRI within 3 months, RECIST measurements
Wrong formulation Confirm tablets vs capsules FDA labeling for specific indication
Not medically necessary Strengthen clinical rationale Guidelines, peer-reviewed studies, expert opinion

Appeals Process for Cigna in New York

Level 1: Internal Appeal

  • Deadline: 180 days from denial date
  • Timeline: 30 days for standard, 15 days for urgent
  • Submit: Cigna member portal or written request
  • Required: Denial letter, additional clinical evidence, prescriber support

Level 2: External Review (New York State)

  • Deadline: 4 months after final internal denial
  • Timeline: 30 days standard, 72 hours expedited
  • Authority: New York State Department of Financial Services
  • Cost: Up to $25 (waived for financial hardship)
From our advocates: We've seen many Cabometyx denials overturned on external review when patients submit comprehensive treatment histories and current clinical guidelines. The key is demonstrating that standard alternatives have been tried and failed, with specific dates and documented reasons for each treatment change. New York's external review process is particularly thorough in evaluating oncology cases.

Renewals and Reauthorization

When do I need to renew authorization?

Cigna typically approves Cabometyx for 1-year periods. Renewal requires:

  • Evidence of therapeutic benefit (stable disease or response)
  • Continued medical necessity
  • Updated imaging and laboratory values
  • Tolerability assessment

Submit renewal requests 30-60 days before expiration to avoid treatment gaps.

Specialty Pharmacy Requirements

Why was my prescription transferred to Accredo?

Cigna requires specialty medications like Cabometyx to be dispensed through designated specialty pharmacies. Benefits include:

  • Prior authorization coordination
  • Financial assistance screening
  • Clinical monitoring and support
  • Direct delivery to your home

What if I prefer a different pharmacy?

You may request an exception, but it requires additional documentation and may result in higher out-of-pocket costs. Most patients find specialty pharmacies provide better support for complex medications.

Troubleshooting Common Issues

Portal access problems

  • Contact Cigna member services for login assistance
  • Ensure your browser allows cookies and JavaScript
  • Try accessing during off-peak hours

Missing forms or documentation

  • Request copies from your oncology clinic
  • Use Cigna's secure messaging for document submission
  • Keep copies of all submissions with confirmation numbers

Prescription delays

  • Verify prior authorization status first
  • Check with specialty pharmacy for processing updates
  • Contact prescriber if clinical information is needed

New York External Appeal Rights

New York residents have strong appeal rights when Cigna denies coverage for medically necessary treatments. If your internal appeal is denied, you can request an external review through the New York State Department of Financial Services.

How to File an External Appeal

  1. Complete the application within 4 months of final denial
  2. Gather supporting documents:
    • Cigna's denial letter
    • Medical records and physician attestation
    • Relevant clinical literature
  3. Submit by mail or fax:
    • Standard: Mail to DFS, 99 Washington Ave, Box 177, Albany, NY 12210
    • Expedited: Fax to 888-990-3991
  4. Pay filing fee ($25, refunded if successful)

For assistance, contact Community Health Advocates at 888-614-5400 or DFS at 800-400-8882.

What Makes a Strong External Appeal

  • Detailed treatment chronology with outcomes
  • Citations to FDA labeling and clinical guidelines
  • Expert physician opinion supporting medical necessity
  • Evidence that Cigna's denial contradicts medical standards

Counterforce Health helps patients and clinicians prepare comprehensive appeals by analyzing denial letters, identifying specific coverage criteria, and assembling targeted medical evidence that addresses payer concerns point-by-point.

Frequently Asked Questions

How long does Cigna prior authorization take in New York? Standard review is 72 hours, expedited is 24 hours. New York law requires timely processing, and delays can be reported to the state insurance department.

What if Cabometyx is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, if waiting would seriously jeopardize your health. Your oncologist must provide written attestation of medical urgency.

Does step therapy apply if I failed treatments in another state? Yes, document all prior therapies regardless of where they were tried. Include treatment dates, outcomes, and reasons for discontinuation.

What happens if I miss an appeal deadline? Appeal deadlines are generally strict. Contact a patient advocate immediately to explore options, which may include filing a complaint with New York regulators.

Sources & Further Reading

Disclaimer: This information is for educational purposes and is not medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for decisions about your specific situation. For personalized assistance with prior authorizations and appeals, consider consulting with healthcare coverage specialists who understand payer-specific requirements.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.