By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Humana in Ohio: Complete PA Guide and Appeals Process

Quick Answer: Cabometyx (cabozantinib) requires prior authorization from Humana in Ohio. Your oncologist must submit clinical documentation including diagnosis, staging, prior therapies, and medical necessity justification. If denied, you have 65 days to appeal internally, then can request external review through Ohio's Department of Insurance. Start by having your doctor complete Humana's PA form via their provider portal or fax to 1-877-486-2621.

Table of Contents

Understanding Humana's Coverage Types in Ohio

Humana operates several plan types in Ohio, each with different coverage rules for specialty oncology drugs like Cabometyx (cabozantinib):

Medicare Advantage Plans: These are Humana's most common plans in Ohio. They follow Medicare Part D rules for prescription drugs, with prior authorization requirements for high-cost specialty medications.

Commercial Plans: Available through employers or the marketplace, these plans have their own formularies and may have stricter step therapy requirements than Medicare plans.

Medicaid (Humana Healthy Horizons): Ohio Medicaid recipients enrolled in Humana's managed care plan have access to external medical review processes specific to the state's Medicaid program.

Note: Self-funded employer plans follow federal ERISA rules rather than Ohio state insurance regulations, which affects your appeal rights.

Cabometyx Formulary Status and Tiers

Cabometyx typically appears on Humana formularies as a Tier 5 specialty drug, requiring prior authorization regardless of your plan type. The medication is covered for FDA-approved indications including:

  • Advanced renal cell carcinoma (RCC)
  • Hepatocellular carcinoma after sorafenib
  • RAI-refractory differentiated thyroid cancer in patients ≥12 years

Important: Cabometyx tablets and Cometriq capsules (both containing cabozantinib) are not interchangeable. Ensure your prescription specifies the correct formulation for your diagnosis.

Prior Authorization Requirements

Medical Necessity Documentation

Your oncologist must provide comprehensive clinical documentation to establish medical necessity. Based on Humana's requirements, this includes:

Required Element Details Source Needed
Cancer Diagnosis Specific type with ICD-10 codes Pathology report
Disease Staging Current stage and progression Recent imaging (CT/MRI)
Prior Treatments All previous therapies with dates and outcomes Treatment records
Laboratory Values Kidney/liver function tests Recent labs
Clinical Rationale Why Cabometyx is appropriate now Provider letter
Guideline Support NCCN or FDA references Published guidelines

Clinician Corner: Medical Necessity Letter Checklist

Healthcare providers should include these key elements in their medical necessity letters:

✓ Patient demographics and diagnosis with specific cancer type and stage
✓ Treatment history including dates, durations, and reasons for discontinuation
✓ Clinical rationale for Cabometyx based on current guidelines
✓ Contraindications to formulary alternatives, if applicable
✓ Monitoring plan for potential side effects and drug interactions
✓ References to NCCN guidelines or FDA labeling supporting the indication

Specialty Pharmacy Network

Cabometyx must be dispensed through Humana's approved specialty pharmacy network. In Ohio, this typically means:

  • Humana Pharmacy Solutions for most Medicare Advantage members
  • Network specialty pharmacies that meet Ohio Board of Pharmacy licensing requirements
  • Prior authorization completion before the first fill
Tip: Contact Humana member services at the number on your insurance card to confirm which specialty pharmacies serve your Ohio location.

Cost-Share Basics

Understanding your costs helps you plan for treatment:

Medicare Advantage: Most members pay 25-33% coinsurance for Tier 5 specialty drugs after meeting their deductible. Annual out-of-pocket maximums provide cost protection.

Commercial Plans: Cost-sharing varies widely. Check your Summary of Benefits and Coverage (SBC) for specialty drug coinsurance rates.

Manufacturer Support: Exelixis offers copay assistance that may reduce your out-of-pocket costs, subject to eligibility requirements.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: You and your oncology team
What: Insurance card, complete treatment history, recent labs and imaging
Timeline: 1-2 days

2. Complete Prior Authorization Request

Who: Your oncologist's office
How: Submit via Humana provider portal or fax to 1-877-486-2621
Timeline: Same day submission

3. Include Comprehensive Clinical Support

Who: Your oncologist
What: Medical necessity letter addressing all criteria above
Key: Reference specific NCCN guidelines or FDA labeling

4. Request Expedited Review (if applicable)

Who: Your doctor
When: If treatment delay could endanger your health
Timeline: 24-hour decision for expedited requests

5. Track Your Request

Who: You or your care team
How: Through Humana's member/provider portal
Timeline: 72 hours for standard requests

6. Set Up Specialty Pharmacy

Who: You, with help from your oncology team
What: Contact Humana's specialty pharmacy partner
Timeline: 1-2 days after approval

7. Prepare for Potential Appeal

Who: You and your oncologist
What: Keep copies of all documentation
Why: 65-day appeal deadline starts from denial notice

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient clinical information Resubmit with complete medical necessity letter Treatment history, labs, imaging
Step therapy not completed Document prior failures or contraindications Previous treatment records
Wrong formulation Clarify Cabometyx tablets vs. Cometriq capsules Corrected prescription
Off-label use Provide guideline support for indication NCCN guidelines, literature
Drug interactions Address safety concerns Medication reconciliation, monitoring plan

Appeals Process for Ohio Residents

If Humana denies your Cabometyx request, Ohio residents have specific appeal rights:

Internal Appeals with Humana

  • Timeline: 65 days from denial notice to file
  • Decision: 7 calendar days for Humana to respond
  • How: Submit via member portal or mail

External Review through Ohio Department of Insurance

After exhausting Humana's internal appeals, you can request an independent external review:

  • Eligibility: Must complete all internal appeals first
  • Timeline: 4 months (180 days) from final denial to request
  • Process: Contact Ohio Department of Insurance at 800-686-1526
  • Decision: Independent medical experts review your case
  • Binding: If approved, Humana must cover the treatment
From our advocates: We've seen many Ohio patients succeed in external review when their oncologists provided detailed letters explaining why formulary alternatives weren't suitable. The key is showing you've tried standard options and need Cabometyx specifically for your cancer type and stage.

Medicaid External Medical Review

Ohio Medicaid recipients with Humana Healthy Horizons can also use Humana's EMR process for certain denials.

When to Escalate

Contact the Ohio Department of Insurance Consumer Hotline at 800-686-1526 if:

  • Humana doesn't respond within required timeframes
  • You're unsure about external review eligibility
  • You need help navigating the appeals process

For urgent situations where treatment delay could harm your health, always request expedited review at each level.

FAQ

How long does Humana prior authorization take for Cabometyx in Ohio?
Standard requests: 72 hours. Expedited requests (when delay could endanger health): 24 hours. Your doctor can request expedited review if clinically appropriate.

What if Cabometyx isn't on Humana's formulary?
You can request a formulary exception with your doctor's support showing medical necessity and why covered alternatives aren't suitable.

Can I get a temporary supply while waiting for approval?
New Humana members may qualify for a 30-day transition fill during their first 90 days of enrollment. Contact member services to verify eligibility.

Does step therapy apply if I failed treatments in another state?
Yes, treatment failures from other states count toward step therapy requirements. Ensure your doctor includes complete treatment history from all providers.

What's the difference between Cabometyx and Cometriq?
Both contain cabozantinib but are different formulations for different cancers. Cabometyx (tablets) treats kidney, liver, and thyroid cancers. Cometriq (capsules) treats medullary thyroid cancer. They're not interchangeable.

Can I appeal if I have employer insurance through Humana?
It depends on whether your plan is fully insured (Ohio appeals apply) or self-funded (federal ERISA rules apply). Check with HR or call the member services number on your card.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed strategies. Our platform analyzes denial letters, identifies specific policy requirements, and generates targeted rebuttals that address payer criteria point-by-point. Learn more about our approach to getting specialty medications approved.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan, medical condition, and clinical circumstances. Always consult with your healthcare provider about treatment options and work with your insurance company directly for coverage determinations. For questions about Ohio insurance regulations or to file complaints, contact the Ohio Department of Insurance at 800-686-1526.

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