By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (cabozantinib) Covered by Cigna in Washington: Complete Guide to Prior Authorization, Appeals, and Cost Assistance

Quick Answer: Cabometyx (cabozantinib) requires prior authorization from Cigna in Washington. Your oncologist submits documentation through CoverMyMeds or ExpressPAth with diagnosis, prior therapy failures, and medical necessity justification. Standard approval takes 72 hours; denials can be appealed through Cigna's internal process, then external review via Washington's Independent Review Organization. Contact Washington's Office of the Insurance Commissioner at 800-562-6900 for appeal assistance.

Table of Contents

  1. Coverage Requirements Overview
  2. Prior Authorization Process
  3. Cost Factors and Benefit Design
  4. Manufacturer Assistance Programs
  5. Specialty Pharmacy Coordination
  6. Appeals Process in Washington
  7. Common Denial Reasons and Solutions
  8. Annual Renewal Considerations
  9. Scripts for Key Conversations
  10. FAQ

Coverage Requirements Overview

Cabometyx (cabozantinib) is classified as a specialty tier medication under Cigna plans, requiring prior authorization for all FDA-approved indications including renal cell carcinoma, hepatocellular carcinoma, and radioactive iodine-refractory differentiated thyroid cancer.

Coverage at a Glance

Requirement Details Timeline Source
Prior Authorization Required for all indications 72 hours standard, 24 hours expedited Cigna PA Policy
Specialty Tier 20-33% coinsurance or $150-$500 copay Varies by plan Plan formulary documents
Specialty Pharmacy Accredo or Express Scripts only 3-5 business days after approval Provider coordination
Step Therapy May apply depending on diagnosis Override available with documentation Formulary Exception Process

Prior Authorization Process

Your oncologist must initiate the prior authorization request with comprehensive clinical documentation.

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • FDA-approved diagnosis with ICD-10 codes
    • Complete treatment history with dates, dosages, outcomes
    • Recent imaging or lab results
    • Timeline: 1-2 days to compile
  2. Submit PA Request (Prescriber)
    • Use CoverMyMeds or ExpressPAth portal
    • Include medical necessity letter
    • Attach all supporting clinical records
    • Timeline: Same day submission
  3. Cigna Review Process (Cigna)
    • Standard review: up to 72 hours
    • Expedited review: 24 hours for urgent cases
    • Notification sent to prescriber and patient
  4. Specialty Pharmacy Coordination (If Approved)
    • Accredo contacts patient within 24-48 hours
    • Verify insurance benefits and copay assistance
    • Schedule medication shipment
    • Timeline: 3-5 business days to delivery

Clinician Corner: Medical Necessity Documentation

Your oncologist's medical necessity letter should include:

  • Specific diagnosis with staging information
  • Prior therapy history including dates, dosages, duration, and reasons for discontinuation
  • Clinical rationale for Cabometyx based on FDA labeling or NCCN guidelines
  • Contraindications to preferred formulary alternatives
  • Treatment goals and expected outcomes
  • Monitoring plan including frequency and parameters
Tip: Include specific dates and quantifiable outcomes (e.g., "Progressive disease on CT scan dated MM/DD/YYYY showing 25% increase in target lesions") rather than general statements.

Cost Factors and Benefit Design

Understanding your plan's benefit structure helps predict and manage out-of-pocket costs.

What Drives Cabometyx Costs

Specialty Tier Placement: Cabometyx is typically placed on the highest formulary tier, resulting in:

  • Coinsurance of 20-33% of drug cost
  • Or fixed copays ranging from $150-$500 per month
  • Application toward specialty deductible (often $500-$2,000 annually)

Benefit Investigation Checklist

When calling Cigna member services, ask for:

  • Exact specialty tier copay or coinsurance percentage
  • Annual specialty deductible amount and current status
  • Out-of-pocket maximum and progress toward limit
  • Coverage duration (typically 12 months)
  • Required specialty pharmacy network

Manufacturer Assistance Programs

Exelixis offers comprehensive support through their EASE (Exelixis Access Services) program.

Commercial Insurance Patients

Co-Pay Card Program

  • Eligible patients pay $0 per month
  • Available only for commercial insurance (not Medicare, Medicaid, or other government plans)
  • Annual and transaction limits apply
  • Enroll at activatethecard.com/exelixis

Financial Need-Based Assistance

EASE Patient Assistance Program

  • Free medication for qualifying uninsured or underinsured patients
  • Financial need assessment required (specific income limits not publicly disclosed)
  • Application through DocuSign or fax via healthcare provider
  • Contact: EASE Program

Counterforce Health helps patients navigate these assistance programs alongside insurance appeals, ensuring you access all available support while pursuing coverage approval.

Specialty Pharmacy Coordination

Cabometyx must be dispensed through Cigna's designated specialty pharmacy network.

Accredo Coordination Process

  1. Initial Contact: Accredo calls within 24-48 hours of PA approval
  2. Benefit Verification: Confirms coverage details and patient responsibility
  3. Copay Assistance: Enrolls eligible patients in manufacturer programs
  4. Shipment Scheduling: Coordinates delivery timing with patient preferences
  5. Ongoing Support: Provides refill reminders and clinical monitoring coordination
Note: Ensure your prescription specifies "Cabometyx tablets" rather than generic cabozantinib capsules, as they are not interchangeable formulations.

Appeals Process in Washington

Washington state provides robust appeal rights through the Office of the Insurance Commissioner (OIC).

Internal Appeals Timeline

Appeal Level Decision Timeframe Submission Method
First Level Internal 14-30 days (pre-service), 14-60 days (post-service) Cigna member portal or written request
Second Level Internal 14-30 days (pre-service), 14-60 days (post-service) Follow first-level instructions
Expedited (Urgent) 72 hours or less Phone or written with urgency documentation

External Review Rights

After completing Cigna's internal appeals, Washington residents can request independent external review:

  • Timeline: 15-20 days for standard cases, 72 hours for urgent situations
  • Process: Submit request to OIC or directly to Cigna
  • IRO Assignment: Washington OIC assigns Independent Review Organization
  • Decision: Binding on Cigna if overturned
  • Cost: No charge to patient

Contact Washington OIC: 800-562-6900 for appeal assistance

Appeals Playbook for Cigna in Washington

  1. File Internal Appeal (Within 180 days of denial)
    • Submit additional clinical evidence
    • Request peer-to-peer review if available
    • Include updated treatment response data
  2. Request External Review (After final internal denial)
    • Contact OIC at 800-562-6900
    • Submit within 180 days of final internal denial
    • Provide 5 business days for additional documentation
  3. Escalate to OIC Complaint (Parallel process)
    • File separate complaint for unfair claim practices
    • Does not affect appeals timeline
    • Additional consumer protection avenue

Common Denial Reasons and Solutions

Denial Reason Documentation to Include Appeal Strategy
"Not medically necessary" FDA labeling, NCCN guidelines, peer-reviewed studies Emphasize evidence-based standard of care
Wrong formulation Prescription specifying tablets, clinical rationale Highlight tablet-specific FDA approval
Insufficient prior therapy Detailed treatment history with dates and outcomes Document specific failures or intolerances
Off-label use Published studies, specialty guidelines, drug compendia Cite recognized medical literature
Drug interactions Medication reconciliation, management plan Show interaction monitoring and mitigation

From Our Advocates

"We've seen Washington patients successfully overturn Cabometyx denials by providing comprehensive imaging progression data alongside detailed prior therapy timelines. The key is quantifying disease progression with specific measurements and dates, rather than general statements about treatment failure. Washington's external review process has been particularly effective for oncology appeals when robust clinical evidence is presented."

Annual Renewal Considerations

Plan changes can affect Cabometyx coverage each plan year.

Renewal Checklist

  • Formulary Status: Verify Cabometyx remains covered
  • Tier Placement: Check for any tier changes affecting cost
  • PA Requirements: Confirm continued prior authorization needs
  • Specialty Pharmacy: Ensure network pharmacy remains in-network
  • Benefit Limits: Review annual maximums and deductibles
Tip: Submit renewal PA requests 30-60 days before current authorization expires to avoid treatment interruptions.

Scripts for Key Conversations

Calling Cigna Member Services

"I need to verify coverage for Cabometyx tablets for my cancer treatment. Can you tell me the exact copay amount, which specialty pharmacy I must use, and confirm that prior authorization has been approved? I also need to know my current progress toward my out-of-pocket maximum."

Requesting Peer-to-Peer Review

"We're requesting a peer-to-peer review for our Cabometyx prior authorization denial. The patient has advanced renal cell carcinoma with documented progression on first-line therapy. We have comprehensive imaging and treatment history available for clinical discussion with your medical director."

Contacting Washington OIC

"I need assistance with a Cigna denial for Cabometyx, a cancer medication. I've completed their internal appeals process and want to request external review through an Independent Review Organization. Can you guide me through the process and timeline?"

FAQ

How long does Cigna prior authorization take for Cabometyx in Washington? Standard review takes up to 72 hours; expedited review for urgent cases is completed within 24 hours once all documentation is received.

What if Cabometyx is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification showing medical necessity and lack of suitable formulary alternatives. The process follows the same PA timeline.

Can I request expedited appeal in Washington? Yes, both internal appeals and external reviews can be expedited if delay would jeopardize your health. Contact Cigna or the OIC to request urgent processing.

Does step therapy apply if I've tried treatments outside Washington? Treatment history from other states counts toward step therapy requirements. Provide comprehensive documentation of all prior therapies regardless of location.

What happens if both internal and external appeals are denied? You may pursue legal action through Washington courts, though this is rare. Consider consulting with a healthcare attorney who specializes in insurance disputes.

How do I know if my plan is eligible for Washington external review? Fully-insured plans purchased in Washington are eligible. Self-funded employer plans may have different rules. The OIC can verify your plan's appeal rights.

Can I continue treatment while appealing? For urgent medical needs, you may be able to get temporary coverage during the appeal process. Discuss continuity of care options with your oncologist and Cigna.

What if I can't afford the specialty tier copay? Commercial insurance patients may qualify for the Exelixis copay card (reducing cost to $0). Uninsured patients may qualify for free medication through the EASE patient assistance program.

This guide provides general information about insurance appeals and is not medical advice. Always consult with your healthcare provider about treatment decisions and contact the Washington State Office of the Insurance Commissioner at 800-562-6900 for personalized assistance with appeals.

For complex prior authorization challenges, Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals tailored to each plan's specific requirements.

Sources & Further Reading

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