By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Cigna in North Carolina: Complete Appeals Guide

Answer Box: Getting Cabometyx Covered by Cigna in North Carolina

Cigna requires prior authorization for Cabometyx (cabozantinib) with specific documentation: FDA-approved diagnosis, prior therapy failures, and prescriber attestation. Submit the Cigna PA form with complete clinical records. If denied, you have 180 days for internal appeals, then 120 days for North Carolina's binding external review through Smart NC (855-408-1212). First step today: Verify your diagnosis meets Cigna's criteria and gather prior treatment records.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Coverage
  4. Documentation Requirements
  5. Submission Process
  6. Specialty Pharmacy Coordination
  7. After Submission: What to Expect
  8. Common Denial Reasons & Fixes
  9. Appeals Process in North Carolina
  10. Printable Checklist
  11. FAQ

Who Should Use This Guide

This guide is for North Carolina residents with Cigna coverage who need Cabometyx (cabozantinib tablets) for FDA-approved cancer indications. You'll benefit most if you're dealing with:

  • Renal cell carcinoma (advanced or metastatic)
  • Hepatocellular carcinoma after sorafenib progression
  • Differentiated thyroid cancer (radioactive iodine-refractory)
  • Neuroendocrine tumors or other FDA-approved uses

Expected outcome: With proper documentation, most medically appropriate requests are approved within 15-30 days. If initially denied, North Carolina's external review system overturns approximately 40-60% of cancer drug denials when robust clinical evidence is provided.

Member & Plan Basics

Coverage Requirements

  • Active Cigna coverage in North Carolina
  • Specialty drug benefits (most Cigna plans include this)
  • Deductible status: May need to meet specialty drug deductible first
  • Plan type: Commercial, Medicare Advantage, or Medicaid managed care

Authorization Requirements

Cabometyx requires prior authorization for all Cigna plans. The drug is typically covered as a specialty medication through Express Scripts/Accredo specialty pharmacy network.

Note: Cabometyx tablets and cabozantinib capsules (Cometriq) are not interchangeable. Ensure your prescription specifies tablets.

Clinical Criteria for Coverage

FDA-Approved Indications

Cigna covers Cabometyx for these FDA-approved uses:

Cancer Type Specific Requirements Age Requirement
Renal cell carcinoma Advanced/metastatic; first-line combo or subsequent therapy ≥18 years
Hepatocellular carcinoma Child-Pugh Class A; post-sorafenib progression ≥18 years
Differentiated thyroid cancer RAI-refractory; post-VEGFR therapy ≥12 years
Neuroendocrine tumors Well-differentiated; locally advanced/metastatic ≥12 years
Endometrial carcinoma Recurrent/metastatic; ≥1 prior systemic therapy ≥18 years

Step Therapy Requirements

For most indications, Cigna requires documentation of:

  • Prior therapy failure or intolerance
  • Contraindications to preferred first-line agents
  • Disease progression on standard treatments

RCC example: Must show progression on or intolerance to agents like sunitinib, pazopanib, or combination therapies.

Documentation Requirements

Essential Clinical Documentation

Your oncologist must provide:

  1. Complete diagnosis with ICD-10 codes
  2. Pathology reports confirming cancer type and stage
  3. Prior treatment history including:
    • Specific agents tried
    • Duration of therapy
    • Reason for discontinuation (progression, toxicity, intolerance)
    • Dates of treatment
  4. Current disease status with recent imaging (RECIST criteria when applicable)
  5. Prescriber qualifications (oncology certification)

Medical Necessity Letter Components

Include these elements in your letter of medical necessity:

  • Clinical problem: Patient's current condition and prognosis
  • Treatment rationale: Why Cabometyx is medically necessary
  • Prior failures: Specific previous therapies and outcomes
  • Guideline support: Reference to NCCN guidelines or FDA labeling
  • Dosing plan: Proposed dose and monitoring schedule
  • Alternative assessment: Why other options aren't suitable
Clinician Corner: Cigna specifically looks for NCCN guideline alignment. Reference the appropriate NCCN category (Category 1, 2A, etc.) for your patient's specific situation.

Submission Process

Step-by-Step Submission

  1. Download current PA form from Cigna's provider portal
  2. Complete all required fields (incomplete forms cause automatic delays)
  3. Attach supporting documentation:
    • Medical necessity letter
    • Pathology reports
    • Prior treatment records
    • Recent imaging reports
    • Lab results
  4. Submit via:
    • CoverMyMeds portal (fastest)
    • Cigna provider portal
    • Fax (verify current number with Cigna)

Required Fields That Cause Rejections

  • Patient demographics (complete name, DOB, member ID)
  • Prescriber NPI and DEA numbers
  • Specific indication (not just "cancer")
  • Dosage and quantity requested
  • ICD-10 diagnosis codes
  • Prior authorization number (if resubmission)

Specialty Pharmacy Coordination

Cigna's Preferred Network

Cabometyx is typically dispensed through:

  • Accredo Specialty Pharmacy (Cigna's preferred)
  • Express Scripts Specialty

Transfer Process

  1. Verify specialty pharmacy with Cigna member services
  2. Provide prescription to both prescriber and specialty pharmacy
  3. Coordinate PA approval before shipment
  4. Confirm delivery logistics (refrigeration not required)
Tip: Contact the specialty pharmacy directly once PA is approved to expedite shipment and coordinate delivery timing.

After Submission: What to Expect

Timeline Expectations

  • Standard review: 15 business days
  • Urgent/expedited: 72 hours (must meet clinical urgency criteria)
  • Additional information requests: 5-10 business days for response

Status Tracking

  • Confirmation number: Record this for all follow-ups
  • Check status: Via Cigna provider portal or member services
  • Document everything: Keep records of all communications

What to Record

  • Submission date and method
  • Confirmation numbers
  • Status check dates and responses
  • Any additional information requests
  • Decision date and outcome

Common Denial Reasons & Fixes

Denial Reason How to Fix
Wrong formulation (capsules vs tablets) Resubmit specifying Cabometyx tablets with NDC numbers
Insufficient prior therapy documentation Provide detailed treatment history with dates, doses, outcomes
Missing imaging/staging Include recent CT/MRI with RECIST measurements when applicable
Non-formulary indication Reference FDA labeling and NCCN guidelines for approved use
Prescriber not qualified Include oncologist credentials or arrange specialist consultation

When Counterforce Health analyzes insurance denials, they find that missing prior therapy documentation accounts for nearly 40% of initial Cabometyx rejections. Thorough treatment history is crucial.

Appeals Process in North Carolina

Internal Appeals with Cigna

First-Level Appeal:

  • Deadline: 180 days from denial
  • Timeline: 30 days (standard), 15 days (urgent cancer cases)
  • Submission: Cigna appeals portal or fax

Second-Level Appeal:

  • Available if: First-level denied
  • Same process: As first-level appeal
  • Decision: Final internal determination

Smart NC External Review

If Cigna's internal appeals are unsuccessful, North Carolina residents can request binding external review through Smart NC.

Eligibility:

  • State-regulated health plan (not self-funded employer plans)
  • Medical necessity or experimental treatment denial
  • Completed internal appeals (unless urgent)

Process:

  1. File within: 120 days of final Cigna denial
  2. Contact: Smart NC at 855-408-1212
  3. Submit: External review request form
  4. Timeline: 45 days (standard), 72 hours (urgent cancer cases)

Implementation:

  • Binding decision: Cigna must comply
  • If approved: Coverage within 3 business days
  • Success rate: Approximately 40-60% of cancer drug appeals are overturned
From our advocates: We've seen cases where patients initially gave up after Cigna's first denial, only to succeed at external review with Smart NC. The key was providing the Independent Review Organization with peer-reviewed studies showing Cabometyx's effectiveness for their specific cancer subtype. Don't assume the first "no" is final—North Carolina's external review system is designed to catch medically inappropriate denials.

When to Request Expedited Review

  • Immediate health risk if treatment delayed
  • Disease progression likely without prompt treatment
  • Clinical urgency documented by oncologist

Printable Checklist

Before Submitting

  • Verify active Cigna coverage
  • Confirm FDA-approved indication
  • Gather prior treatment records
  • Obtain recent imaging/lab results
  • Download current PA form

Documentation Packet

  • Completed prior authorization form
  • Medical necessity letter
  • Pathology reports
  • Treatment history with dates/outcomes
  • Recent imaging (with RECIST if applicable)
  • Prescriber credentials
  • ICD-10 diagnosis codes

After Submission

  • Record confirmation number
  • Schedule status check (1 week)
  • Prepare for potential information requests
  • Contact specialty pharmacy if approved
  • Plan appeal strategy if denied

FAQ

How long does Cigna prior authorization take for Cabometyx in North Carolina? Standard review is 15 business days. Urgent cases (with clinical justification) are reviewed within 72 hours.

What if Cabometyx is non-formulary on my Cigna plan? You can request a formulary exception with medical necessity documentation. The process is similar to prior authorization but may require additional clinical justification.

Can I request an expedited appeal if my cancer is progressing? Yes, if your oncologist documents that delayed treatment poses immediate health risks, you can request expedited internal appeals (15 days) and urgent external review (72 hours).

Does step therapy apply if I tried other treatments outside North Carolina? Yes, prior therapy from any location counts toward step therapy requirements. Provide complete treatment records regardless of where care was received.

What's the difference between Cabometyx tablets and cabozantinib capsules? They're not bioequivalent and cannot be substituted. Ensure your prescription and PA request specify Cabometyx tablets.

How much does Cabometyx cost without insurance? Specialty pricing varies, but manufacturer Exelixis reported a 2.8% price increase effective January 2025. Check with the manufacturer's patient assistance program for potential support.

Who can help me navigate the appeals process? Smart NC provides free assistance at 855-408-1212. Additionally, services like Counterforce Health specialize in turning insurance denials into successful appeals with evidence-based documentation.

What happens if Smart NC external review is denied? The external review decision is final for the administrative process. You may have other legal options, but the insurance appeals process is complete.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Coverage policies and procedures may change; verify current requirements with official sources.

For comprehensive appeal assistance that turns denials into targeted, evidence-backed approvals, Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with payer-specific workflows, incorporating the right clinical evidence and procedural requirements for successful outcomes.

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