By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Cigna in Virginia: Complete Guide to Prior Authorization, Appeals, and State Protections

Quick Answer: To get Cabometyx (cabozantinib) covered by Cigna in Virginia, your doctor must submit a prior authorization through CoverMyMeds or ExpressPAth within 72 hours for standard review (24 hours if expedited). If denied, file an internal appeal within 180 days, then request external review through Virginia's Bureau of Insurance within 120 days. Virginia law requires step therapy exceptions for contraindications or prior failures, and cancer patients can bypass internal appeals for immediate external review.

Table of Contents

Why Virginia State Rules Matter

Virginia's insurance laws provide crucial protections that work alongside Cigna's policies to ensure fair coverage decisions. Unlike some states, Virginia allows cancer patients to request external review without exhausting internal appeals first—a significant advantage when you need Cabometyx quickly.

The state's step therapy override law requires Cigna to grant exceptions within 72 hours (24 hours for urgent cases) if you meet specific criteria like prior drug failures or contraindications. This applies to all prescription drugs, including specialty oncology medications like Cabometyx.

Virginia's commercial insurance market is competitive, with Cigna holding significant market share after Anthem Blue Cross Blue Shield. Understanding both Cigna's national policies and Virginia's state-specific protections gives you the strongest foundation for approval.

Cigna's Prior Authorization Requirements

Cabometyx (cabozantinib) typically requires prior authorization through Cigna's specialty pharmacy network, managed by Express Scripts and Accredo. The medication is indicated for:

  • Renal cell carcinoma (RCC): Advanced or metastatic disease
  • Hepatocellular carcinoma (HCC): After sorafenib progression
  • Thyroid cancer: RAI-refractory differentiated thyroid cancer after VEGFR therapy

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all indications Cigna Formulary
Formulary Tier Specialty tier (higher copay) Member portal or pharmacy
Step Therapy May apply depending on indication Provider portal during submission
Quantity Limits Standard dosing per FDA label Cigna policy documents
Site of Care Specialty pharmacy required Accredo or Express Scripts

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Complete diagnosis with ICD-10 codes
    • Prior therapy history and outcomes
    • Current labs and imaging results
    • Timeline: 1-2 business days
  2. Submit Prior Authorization (Prescriber)
    • Use CoverMyMeds or ExpressPAth portal
    • Include medical necessity letter
    • Attach supporting clinical documentation
    • Timeline: Same day submission possible
  3. Cigna Review Process
  4. If Approved
    • Prescription routed to Accredo Specialty Pharmacy
    • Patient contacted for delivery coordination
    • Timeline: 3-5 business days for first fill
  5. If Denied
    • Review denial letter for specific reasons
    • Prepare appeal documentation
    • Consider peer-to-peer review request
    • Next step: Internal appeal process

Virginia's Step Therapy Protections

Virginia Code § 38.2-3407.9:05 provides strong protections against inappropriate step therapy requirements. Cigna must grant an exception if your prescriber documents any of these criteria:

Automatic Exception Criteria

  • Contraindication: The required step drug would be harmful
  • Ineffectiveness: Based on your clinical characteristics or current medications
  • Prior failure: You've tried the step drug before with poor results or intolerance
  • Current stability: You're already stable on the prescribed medication
Tip: Have your oncologist specifically reference Virginia law when requesting step therapy exceptions. The 72-hour response requirement is legally binding.

Required Response Times

  • Standard requests: 72 hours maximum
  • Urgent circumstances: 24 hours (including weekends)
  • Documentation: Clinical justification must support the exception criteria

Appeals Process: Internal and External

Internal Appeals with Cigna

If your initial prior authorization is denied, you have 180 days to file an internal appeal:

How to File:

  • Submit through Cigna member portal or provider portal
  • Fax to 1-866-873-8279 if electronic options unavailable
  • Include enhanced clinical documentation and medical necessity letter

Timeline:

  • Standard appeal: 72 hours for determination
  • Expedited appeal: 24 hours if delay could harm health

External Review Through Virginia

Virginia's external review process is managed by the State Corporation Commission Bureau of Insurance:

Key Advantages:

  • Cancer patients can bypass internal appeals
  • Independent medical review by specialists
  • Binding decision on Cigna
  • No cost to patients

How to File:

  • Submit Form 216-A within 120 days of denial
  • Mail to: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  • Phone: 1-877-310-6560
  • Email: [email protected]

Timeline:

  • Standard review: 45 days maximum
  • Expedited review: 72 hours for urgent cases
From our advocates: One patient with metastatic RCC had their Cabometyx denial overturned through Virginia's external review after Cigna initially required step therapy with sunitinib. The independent reviewer agreed that the patient's cardiac history made sunitinib inappropriate, and coverage was approved within the expedited 72-hour timeline.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Step therapy required Request Virginia exception Prior therapy records, contraindication notes
Off-label use Provide clinical guidelines NCCN guidelines, published studies
Insufficient prior therapy Document treatment history Pharmacy records, prior authorizations
Wrong formulation Clarify tablet vs. capsule Prescriber clarification letter
Medical necessity unclear Enhanced clinical letter Imaging, labs, treatment goals

Clinician Corner: Medical Necessity Letter Checklist

When writing medical necessity letters for Cabometyx, include:

  • Specific diagnosis with ICD-10 codes and staging
  • Prior treatments with dates, durations, and outcomes
  • Clinical rationale for Cabometyx over alternatives
  • Guideline support from NCCN or FDA labeling
  • Monitoring plan and treatment goals
  • Contraindications to formulary alternatives

Reference the FDA prescribing information and relevant NCCN guidelines to strengthen your case.

When to Contact Virginia Regulators

Contact the Virginia Bureau of Insurance if:

  • Cigna violates response timelines
  • Step therapy exceptions are inappropriately denied
  • Internal appeals process is mishandled
  • You need guidance on external review eligibility

The Bureau's consumer services team at 1-877-310-6560 can provide guidance before filing formal complaints or external reviews.

Costs and Patient Assistance

Cabometyx is a high-cost specialty medication, but several assistance options are available:

Manufacturer Support

  • Exelixis Patient Assistance Program: Income-based free drug program
  • Copay assistance: Up to $25,000 annually for eligible patients
  • Information: Visit Exelixis patient support (verify current programs)

Foundation Grants

  • CancerCare Co-Payment Assistance Foundation
  • Patient Access Network Foundation
  • Leukemia & Lymphoma Society

Virginia-Specific Resources

  • Virginia's expanded Medicaid program covers specialty oncology drugs
  • Virginia Cancer Institute patient navigation services

FAQ

How long does Cigna prior authorization take in Virginia? Standard review is 72 hours maximum, with expedited review in 24 hours for urgent cases. Virginia law enforces these timelines.

What if Cabometyx is non-formulary on my Cigna plan? Request a formulary exception through the same prior authorization process. Include clinical justification for why formulary alternatives are inappropriate.

Can I request an expedited appeal in Virginia? Yes, if your oncologist certifies that waiting could jeopardize your health. Expedited external reviews are decided within 72 hours.

Does step therapy apply if I failed medications under a previous insurer? Virginia law requires Cigna to accept prior failures from other insurers. Provide documentation of previous treatments and outcomes.

What happens if my external review is denied? The decision is final and binding, but you retain rights to legal action. Consider consulting a healthcare attorney if you believe the denial violates state or federal law.

How do I find my Cigna formulary tier for Cabometyx? Check your member portal or call the number on your insurance card. Cabometyx is typically on the specialty tier.

For patients and clinicians navigating complex prior authorization denials, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned to the plan's own rules, pulling the right clinical evidence and operational details that payers expect.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. For assistance with insurance appeals and prior authorization challenges, visit Counterforce Health.

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