By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Humana in Pennsylvania: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Cabometyx Covered by Humana in Pennsylvania

Cabometyx requires prior authorization from Humana as a Tier 5 specialty drug. Your oncologist must submit comprehensive documentation including diagnosis, staging, prior treatments, and NCCN guideline justification. If denied, Pennsylvania's Independent External Review Program overturns approximately 50% of appeals. First step today: Have your doctor gather your complete treatment history and submit the PA request via Humana's provider portal or fax to 1-877-486-2621.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Request
  5. Follow-Up and Tracking
  6. Typical Timelines
  7. If You're Asked for More Information
  8. If Denied: Your Appeal Options
  9. Renewal and Reauthorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps Pennsylvania patients and their oncologists navigate Humana's prior authorization process for Cabometyx (cabozantinib). Whether you have Humana Medicare Advantage or a commercial plan, you'll learn exactly what documentation to gather, how to submit your request, and what to do if you're initially denied.

Cabometyx is an FDA-approved oral cancer medication used to treat renal cell carcinoma, hepatocellular carcinoma, and certain thyroid cancers. As a specialty oncology drug, it requires prior authorization from all Humana plans and must be dispensed through their specialty pharmacy network.

Who this helps: Patients prescribed Cabometyx, their caregivers, oncology teams, and specialty pharmacy coordinators working with Humana coverage in Pennsylvania.

Before You Start: Verify Your Coverage

Confirm Your Plan Type

Check your Humana insurance card to identify whether you have:

  • Medicare Advantage (appeals follow Medicare timelines)
  • Commercial/Employer plan (may follow ERISA rules)
  • Medicaid managed care (state-specific requirements)

Formulary Status Check

Cabometyx is typically classified as a Tier 5 specialty drug on Humana formularies, meaning higher cost-sharing but covered for FDA-approved indications. You can verify your specific formulary at Humana's member portal.

Important: Cabometyx tablets and Cometriq capsules are not interchangeable. Your prescription must specify the correct formulation for your cancer type to avoid automatic denials.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all plans Humana PA policies
Formulary Tier Tier 5 Specialty Your plan's drug formulary
Step Therapy May apply PA determination letter
Specialty Pharmacy Required Humana Pharmacy Solutions
Quantity Limits 30-day supply typical Plan documents

Gather What You Need

Clinical Documentation Checklist

Your oncologist will need to provide:

Diagnosis Information:

  • Cancer diagnosis with ICD-10 code
  • Pathology report confirming diagnosis
  • Disease staging (TNM or equivalent)
  • Recent imaging with RECIST criteria assessment

Treatment History:

  • Complete list of prior therapies with dates
  • Outcomes of previous treatments (response, progression, intolerance)
  • Reasons for discontinuation of prior medications
  • Documentation of contraindications to preferred alternatives

Current Clinical Status:

  • Recent laboratory results (liver and kidney function)
  • Performance status assessment
  • Current symptoms and functional status
  • Treatment goals and prognosis

Medical Necessity Justification:

  • Reference to current NCCN guidelines supporting Cabometyx use
  • Explanation of why Cabometyx is appropriate for this patient
  • Rationale for timing of therapy initiation

Required Forms

Submit the Request

Fastest Path to Approval: 7 Steps

  1. Prescriber completes PA form with comprehensive clinical documentation
  2. Submit via Humana provider portal or fax to 1-877-486-2621
  3. Include all supporting documents in one complete packet
  4. Request expedited review if urgent (requires medical justification)
  5. Confirm receipt and obtain reference number
  6. Track status via provider portal or member services
  7. Follow up within 48-72 hours if no initial response

Submission Tips

Tip: Submit a complete "request packet" rather than sending documents piecemeal. Incomplete submissions are a common cause of delays.

For urgent cases where treatment delay could harm the patient, your oncologist can request expedited review, which Humana must complete within 24 hours for Medicare plans.

Follow-Up and Tracking

When to Call Humana

  • 48 hours after submission: Confirm receipt and get reference number
  • Day 3-4: Check processing status
  • Day 6-7: Follow up if no decision received (standard timeline is 72 hours)

Sample Call Script for Patients

"Hi, I'm calling to check the status of a prior authorization request for Cabometyx. My member ID is [ID number], and the reference number is [reference number]. Can you tell me the current status and if any additional information is needed?"

Typical Timelines

Pennsylvania Requirements

  • Standard PA decisions: 72 hours for Humana Medicare plans
  • Expedited requests: 24 hours with medical urgency justification
  • Internal appeals: 7 days for Medicare Part D drug appeals
  • External review: 45 days for standard, 72 hours for expedited
Note: Pennsylvania's Independent External Review Program, launched in 2024, has specific timelines that may differ from federal requirements for certain plan types.

If You're Asked for More Information

Common requests include:

  • Additional imaging: Recent scans showing disease progression or response
  • Laboratory values: Updated kidney/liver function tests
  • Treatment timeline clarification: Specific dates of prior therapy starts/stops
  • Guideline references: Current NCCN or other professional society recommendations

Respond promptly to avoid delays. Most additional information requests have 14-day response windows.

If Denied: Your Appeal Options

Common Denial Reasons and Solutions

Denial Reason How to Address
"Not medically necessary" Provide NCCN guidelines and clinical rationale
"Experimental/investigational" Submit FDA approval documentation
Wrong formulation Correct prescription to specify Cabometyx tablets
Step therapy required Document failures/contraindications to preferred drugs
Insufficient documentation Submit complete treatment history and staging

Pennsylvania Appeals Process

Step 1: Internal Appeal (Required First)

  • File within 65 days of denial
  • Submit via Humana member portal or written request
  • Include all supporting clinical documentation
  • Decision within 7 days for drug appeals

Step 2: Independent External Review

  • Available after internal appeal denial
  • File within 4 months of final denial
  • Submit through Pennsylvania Insurance Department
  • Success rate: Approximately 50% of external reviews overturn the insurer's denial
  • Free for consumers
  • Decision binding on both patient and insurer
From our advocates: We've seen cases where patients initially denied for Cabometyx successfully overturned denials by providing comprehensive treatment timelines and current NCCN guideline citations. The key is thorough documentation of why this specific medication is necessary at this point in treatment. While outcomes vary, organized appeals with strong clinical justification tend to be more successful.

Expedited Appeals

For urgent medical situations, both internal and external appeals can be expedited:

  • Internal: 72 hours with physician certification
  • External: 72 hours with medical urgency documentation

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and crafting evidence-backed rebuttals. Their platform helps oncology teams prepare comprehensive prior authorization requests and appeals that align with each payer's specific requirements.

Renewal and Reauthorization

Cabometyx authorizations typically last 12 months. For renewal, you'll need:

  • Updated imaging showing treatment response or stable disease
  • Current laboratory values
  • Clinical notes documenting continued benefit
  • Confirmation of tolerability and absence of significant side effects

Calendar reminder: Start the reauthorization process 30-45 days before your current approval expires to avoid treatment interruption.

Clinician Corner: Medical Necessity Letter Essentials

Healthcare providers should include these key elements:

Patient-Specific Factors:

  • Exact cancer diagnosis with staging
  • Performance status and prognosis
  • Comorbidities affecting treatment options

Treatment Rationale:

  • Current NCCN guideline category and recommendation
  • Why Cabometyx is appropriate for this patient's disease stage
  • Expected treatment goals and monitoring plan

Prior Therapy Documentation:

  • Specific agents tried with dates and durations
  • Reasons for discontinuation (progression, toxicity, intolerance)
  • Response assessment using RECIST or appropriate criteria

Guideline References:

Quick Reference Checklist

Before Submitting

  • Verify Humana plan type and formulary status
  • Confirm correct Cabometyx formulation prescribed
  • Gather complete treatment history with dates
  • Obtain recent imaging and lab results
  • Complete PA form with all required sections

Submission

  • Submit complete packet via provider portal or fax
  • Request expedited review if medically urgent
  • Obtain and record reference number
  • Set follow-up reminders for 48-72 hours

If Denied

  • File internal appeal within 65 days
  • Gather additional supporting documentation
  • Consider peer-to-peer review request
  • Prepare for external review if needed (within 4 months)

FAQ

How long does Humana take to approve Cabometyx in Pennsylvania? Standard prior authorization decisions are made within 72 hours. Expedited requests for urgent medical situations are decided within 24 hours.

What if Cabometyx is non-formulary on my Humana plan? You can request a formulary exception by demonstrating medical necessity and showing that preferred alternatives are inappropriate for your specific situation.

Can I request an expedited appeal in Pennsylvania? Yes, both internal appeals (72 hours) and external reviews (72 hours) can be expedited with physician certification of medical urgency.

Does step therapy apply if I've already failed treatments outside Pennsylvania? Treatment history from any location should count toward step therapy requirements. Provide complete documentation of prior therapies regardless of where they were received.

What's the success rate for Cabometyx appeals in Pennsylvania? While specific data for Cabometyx isn't available, Pennsylvania's Independent External Review Program overturns approximately 50% of insurance denials across all medications and treatments.

How much will Cabometyx cost with Humana coverage? As a Tier 5 specialty drug, you'll typically pay 25-33% coinsurance after meeting your deductible. Exact costs vary by plan. Check with Humana member services for your specific cost-sharing.

For complex cases or if you need assistance preparing appeals documentation, Counterforce Health offers specialized support in converting insurance denials into successful approvals through targeted, evidence-based appeal strategies.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical situation. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department's consumer assistance line or visit pa.gov for resources.

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