By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (Cabozantinib) Covered by Humana in Washington: Complete Appeals Guide

Answer Box: Fastest Path to Approval

Cabometyx (cabozantinib) requires prior authorization from Humana Medicare Advantage in Washington. Your oncologist must submit clinical documentation showing medical necessity, often including step therapy completion. If denied, you have 65 days to appeal internally, then can request external review through Washington's Independent Review Organization within 4 months. Start today: Have your doctor gather your cancer diagnosis, prior failed treatments, and imaging results, then submit the PA request via Humana's provider portal.

Table of Contents

  1. Understanding Your Coverage
  2. Pre-Authorization Preparation
  3. Submitting Your Request
  4. When Humana Says No: Appeals Process
  5. Washington State External Review
  6. Common Denial Reasons & Solutions
  7. Cost-Saving Options
  8. Templates & Scripts
  9. FAQ

Understanding Your Coverage

Cabometyx (cabozantinib) is a specialty oral cancer medication that treats advanced renal cell carcinoma, hepatocellular carcinoma, and certain thyroid cancers. Under Humana Medicare Advantage plans in Washington, this drug requires prior authorization and must be dispensed through their specialty pharmacy network.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Doctor must get approval before you fill Humana PA List
Specialty Pharmacy Must use Humana's network pharmacies Your plan documents
Step Therapy May need to try other drugs first PA determination letter
Quantity Limits Usually 30-day supply maximum Formulary guide
Medical Necessity Must prove cancer diagnosis and clinical need PA submission

Important: Cabometyx tablets and Cometriq capsules are not interchangeable. The FDA label specifically states they have different pharmacokinetics and approved indications. Using the wrong formulation is a common denial reason.

Pre-Authorization Preparation

Before your oncologist submits the request, gather these essential documents:

Clinical Documentation Checklist

  • Cancer diagnosis with ICD-10 codes (C78.00 for RCC, C22.0 for HCC)
  • Pathology report confirming cancer type and staging
  • Imaging results (CT, MRI) showing disease extent
  • Prior treatment history with dates, durations, and outcomes
  • Laboratory values (kidney function, liver function)
  • NCCN guideline citation supporting Cabometyx use
Clinician Corner: For first-line RCC, cite NCCN Guidelines V.3.2025 stating "Cabozantinib + nivolumab is a Category 1 preferred regimen for clear-cell advanced RCC." This carries significant weight in PA reviews.

Medical Necessity Letter Components

Your oncologist's letter should include:

  1. Patient demographics and diagnosis
  2. Cancer staging and prognosis
  3. Prior therapies attempted (if step therapy applies)
  4. Clinical rationale for Cabometyx specifically
  5. NCCN or FDA guideline references
  6. Monitoring plan for side effects

Submitting Your Request

Step-by-Step Submission Process

  1. Doctor completes PA form via Humana provider portal or fax to 1-877-486-2621
  2. Attach required documentation (medical necessity letter, labs, imaging)
  3. Submit within business hours for fastest processing
  4. Track your request using the portal reference number
  5. Expect decision within 72 hours for standard requests
  6. Request expedited review if treatment delay could harm your health

Required Submission Documents

  • Completed PA form
  • Medical necessity letter
  • Recent lab results
  • Imaging studies
  • Prior therapy documentation (if applicable)
  • Insurance card copy

When Humana Says No: Appeals Process

If Humana denies your Cabometyx request, don't give up. Their Medicare Advantage denial rate is only about 3.5%, but appeals often succeed with proper documentation.

Internal Appeal Timeline

  • File within 65 days of receiving denial notice
  • Standard review: 30 days for decision
  • Expedited review: 72 hours if urgent
  • Submit via: Member portal, phone, or mail

Appeal Letter Essentials

Your appeal should address the specific denial reason:

For "not medically necessary" denials:

  • Quote NCCN guidelines supporting Cabometyx use
  • Include peer-reviewed studies showing efficacy
  • Emphasize FDA approval for your cancer type

For step therapy denials:

  • Document all prior treatments tried
  • Explain why alternatives failed or caused intolerable side effects
  • Include dates and durations of previous therapies

For wrong formulation denials:

  • Quote FDA labeling: "Cabometyx tablets and Cometriq capsules are not bioequivalent and should not be substituted"
  • Specify your cancer type requires the tablet formulation

Washington State External Review

If Humana upholds their denial after internal appeals, Washington state offers robust external review protections through Independent Review Organizations (IROs).

External Review Process

  • File within 4 months of final internal denial
  • No cost to you for the review
  • Standard timeline: 45 days maximum
  • Expedited review: 72 hours for urgent cases
  • Contact: Washington Office of Insurance Commissioner at 1-800-562-6900

The IRO assigns independent medical experts to review your case. If they overturn Humana's denial, the insurer must provide coverage.

What to Include in External Review

  • All prior appeal documents
  • Additional medical evidence
  • Oncologist's updated clinical assessment
  • Patient impact statement
From Our Advocates: We've seen Washington patients successfully overturn Cabometyx denials through external review, especially when the appeal included updated NCCN guidelines and clear documentation of why alternative treatments weren't suitable. The key is thorough preparation and using Washington's patient-friendly IRO process.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Not medically necessary" Cite NCCN Category 1 recommendation, include FDA approval documentation
Wrong formulation Quote FDA label on non-interchangeability, specify cancer-appropriate formulation
Step therapy not met Document all prior treatments with dates, outcomes, and intolerance issues
Off-label use Provide clinical studies, expert guidelines supporting the indication
Missing documentation Resubmit with complete medical records, labs, and imaging

Cost-Saving Options

Cabometyx is expensive, but several programs can help reduce your out-of-pocket costs:

Patient Assistance Programs

  • Manufacturer support: Contact Exelixis patient services (verify eligibility)
  • Foundation grants: Organizations like CancerCare offer copay assistance
  • State programs: Washington Apple Health may cover some costs
Note: Medicare beneficiaries have limited access to manufacturer copay cards, but foundation assistance may be available.

Templates & Scripts

Patient Phone Script for Humana

"Hi, I'm calling about prior authorization for Cabometyx for my cancer treatment. My member ID is [ID number]. My oncologist submitted a request on [date]. Can you tell me the status and what additional information might be needed?"

Clinic Staff PA Submission Checklist

  • PA form completed with all required fields
  • Medical necessity letter attached
  • Cancer diagnosis confirmed with ICD-10
  • Prior therapy documentation included
  • Lab results within 30 days attached
  • NCCN guideline citation included
  • Submitted via secure portal or fax

FAQ

Q: How long does Humana prior authorization take for Cabometyx? A: Standard requests receive decisions within 72 hours. Expedited reviews for urgent cases are completed faster, often within 24 hours.

Q: What if Cabometyx isn't on Humana's formulary? A: You can request a formulary exception with strong medical necessity documentation. Your oncologist needs to show why formulary alternatives aren't appropriate.

Q: Can I get expedited approval if my cancer is progressing? A: Yes. If treatment delays could seriously harm your health, request expedited review. Your oncologist should emphasize urgency in the PA request.

Q: Does step therapy apply if I've failed treatments in another state? A: Prior treatment history follows you. Document all previous therapies with medical records, regardless of where treatment occurred.

Q: What's the difference between Cabometyx tablets and Cometriq capsules? A: They're not interchangeable. Cabometyx tablets are approved for RCC and HCC; Cometriq capsules only for thyroid cancer. The FDA specifically prohibits substitution.

Q: How much will Cabometyx cost with Humana coverage? A: Costs vary by plan tier and benefit phase. Specialty drugs typically have higher coinsurance. Contact Humana for your specific copay amount.

Counterforce Health helps patients navigate complex insurance appeals by analyzing denial letters and crafting evidence-backed responses. Their platform identifies specific denial reasons and generates targeted appeals using the right clinical evidence and payer-specific requirements. For patients facing Cabometyx denials, this type of systematic approach—matching clinical evidence to payer criteria—often makes the difference between approval and continued denials. Learn more at CounterforceHealth.org.

The appeals process can feel overwhelming when you're already dealing with cancer treatment. But Washington state provides strong patient protections, and Humana's relatively low denial rate means most medically necessary requests do get approved. The key is thorough preparation and knowing your rights.

If you're still facing challenges after following this guide, consider reaching out to Counterforce Health for specialized appeals assistance, or contact the Washington Office of Insurance Commissioner's consumer helpline for additional support.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult your healthcare provider and insurance plan documents for specific guidance. Coverage policies and requirements may change. Verify all forms, deadlines, and contact information with official sources before taking action.

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