By Counterforce Health Team in Cabometyx (cabozantinib) —

How to Get Cabometyx (cabozantinib) Covered by UnitedHealthcare in Pennsylvania: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Cabometyx Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Cabometyx (cabozantinib) in Pennsylvania, placing it on specialty tier 4-5 with indication-specific criteria. Your fastest path: Have your oncologist submit PA via the UHC Provider Portal with diagnosis confirmation, staging, prior therapy history, and NCCN guideline support. If denied, you have 180 days to appeal internally, then can use Pennsylvania's Independent External Review program (53% overturn rate). Start today by calling UnitedHealthcare member services to verify your exact formulary tier and copay responsibility.

Table of Contents

What Drives Your Cabometyx Costs

UnitedHealthcare typically places Cabometyx (cabozantinib) on specialty tier 4 or 5, meaning you'll pay coinsurance (usually 20-50% of the drug cost) rather than a flat copay. Several factors influence your out-of-pocket costs:

Formulary Tier Placement

  • Cabometyx is managed under UnitedHealthcare's specialty drug policy (Program Number 2024 P 1196-11)
  • Requires prior authorization for all FDA-approved indications
  • Dispensed only through OptumRx specialty pharmacy network
  • Standard 30-day supply limits apply

Plan Design Factors Your specific cost depends on whether you have a commercial employer plan, individual ACA marketplace plan, Medicare Advantage, or Medicaid managed care. Pennsylvania doesn't cap oral cancer drug costs for private insurance like some states do, so your plan's benefit design determines your responsibility.

Note: Self-funded employer plans (ERISA) may have different formularies and appeal processes than fully-insured UnitedHealthcare plans regulated by Pennsylvania.

Benefit Investigation: What to Ask UnitedHealthcare

Before your oncologist submits a prior authorization, gather this essential information by calling the member services number on your insurance card:

Coverage Questions to Ask

  1. "What tier is Cabometyx (cabozantinib tablets) on my specific plan?"
  2. "What's my coinsurance percentage for specialty tier drugs?"
  3. "What's my specialty drug deductible and out-of-pocket maximum?"
  4. "Do I need to use OptumRx Specialty Pharmacy?"
  5. "Does my plan use copay accumulators that limit manufacturer assistance?"

Information to Record

  • Your exact plan name and member ID
  • Prior authorization requirements and forms needed
  • Specialty pharmacy contact information
  • Appeal deadlines and procedures
  • Any step therapy requirements for your cancer type

Counterforce Health helps patients navigate these benefit investigations and can assist with gathering the right documentation for your specific UnitedHealthcare plan.

Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Cabometyx across all cancer indications. Here's what your oncologist needs to submit:

Coverage Criteria by Cancer Type

Cancer Type Requirements Documentation Needed
Renal Cell Carcinoma First-line with nivolumab OR subsequent-line monotherapy Pathology report, staging, prior treatment history
Hepatocellular Carcinoma Subsequent-line after prior systemic therapy Evidence of prior sorafenib or other first-line agent
Differentiated Thyroid Cancer After VEGFR-targeted therapy failure Prior treatment records, RAI-refractory status
Endometrial Carcinoma Second-line or subsequent Treatment history, progression documentation
NSCLC/Other Tumors Diagnosis confirmation Pathology, staging, NCCN guideline support

Required Documentation

Your oncologist should include:

  • Confirmed diagnosis with ICD-10 codes
  • Pathology reports and staging information
  • Complete prior treatment history and responses
  • Recent imaging showing disease status
  • NCCN guideline citations supporting Cabometyx use
  • Medical necessity letter explaining why alternatives aren't appropriate

Submission Process

  1. Submit via UHC Provider Portal (fastest method)
  2. Call 866-889-8054 for urgent cases
  3. Track status through the provider portal
  4. Standard review time: 72 hours with complete documentation
  5. Auto-approval: Patients under 19 years old
Tip: Incomplete submissions cause delays. Ensure all required documents are included with the initial PA request.

Manufacturer Assistance Programs

Exelixis offers two main support programs through EASE (Exelixis Access Services):

Co-Pay Program (Commercial Insurance Only)

  • Eligibility: Commercial insurance that covers Cabometyx (not Medicare, Medicaid, or other government programs)
  • Benefit: May reduce copay to as little as $0 per month
  • Limitations: Annual and per-transaction benefit caps apply
  • Enrollment: Online at ease.us or through your oncologist

Patient Assistance Program (PAP)

  • Eligibility: Uninsured or insured patients who cannot afford Cabometyx
  • Benefit: Free drug for eligible patients
  • Application: Your oncologist completes EASE enrollment form
  • Fax: 1-844-901-3273

Additional Support

  • 30-Day Free Trial: Available regardless of insurance type for new patients
  • Dose Exchange Program: Free 15-tablet supply for dose reductions
Important: Government-insured patients (Medicare, Medicaid) cannot use manufacturer copay cards but may qualify for the Patient Assistance Program.

Formulary Exceptions and Tier Appeals

If Cabometyx is non-formulary or on the highest specialty tier, you can request an exception:

When to Request an Exception

  • No therapeutically equivalent alternatives on lower tiers
  • Medical contraindications to preferred drugs
  • Prior treatment failures with preferred options
  • Documented intolerance to alternatives

Required Documentation

Your oncologist must provide:

  • Medical necessity letter detailing why Cabometyx is specifically needed
  • Prior treatment history with outcomes and adverse events
  • NCCN guideline support (Categories 1, 2A, or 2B preferred)
  • Clinical evidence from peer-reviewed literature
  • Contraindication documentation for preferred alternatives

Exception Process

  1. Submit formulary exception request with PA
  2. Include strengthened clinical documentation
  3. Request expedited review for urgent cases
  4. Appeal if initially denied
  5. Consider external review after internal appeals

Specialty Pharmacy Requirements

UnitedHealthcare requires Cabometyx to be dispensed through their specialty pharmacy network:

Pharmacy Options

  • OptumRx Specialty Pharmacy (primary network pharmacy)
  • Other contracted specialty pharmacies (verify coverage first)
  • Hospital specialty pharmacies (for certain integrated systems)

Coordination Tips

  • Verify your specialty pharmacy is in-network before first fill
  • Ensure PA is on file before shipment
  • Coordinate with manufacturer copay programs
  • Set up automatic refills to avoid treatment gaps
  • Keep backup contact information for urgent needs
Note: Using an out-of-network specialty pharmacy may result in higher costs or no coverage.

Appeals Process in Pennsylvania

If UnitedHealthcare denies your Cabometyx coverage, Pennsylvania offers robust appeal rights:

Internal Appeals (Required First Step)

  • Timeline: 180 days from denial to file appeal
  • Expedited option: Available for urgent medical situations
  • Peer-to-peer review: Request physician-to-physician discussion
  • Documentation: Include all supporting medical records and literature

Pennsylvania Independent External Review

After exhausting internal appeals, Pennsylvania's state-run external review program offers hope:

Success Rate: Approximately 53% of appeals are overturned in favor of patients

Eligibility Requirements:

  • Fully-insured UnitedHealthcare plan (not self-funded ERISA plans)
  • Denial based on medical necessity, experimental/investigational status, or appropriateness
  • Final Adverse Benefit Determination from UnitedHealthcare

Timeline:

  • 4 months to request external review after final denial
  • Standard review: Decision within 45 days
  • Expedited review: Decision within 72 hours for urgent cases

How to File:

  • Online through Pennsylvania Insurance Department portal
  • Mail, fax, or email using PID forms
  • Include all medical records and supporting documentation
From our advocates: "We've seen several Pennsylvania patients successfully overturn UnitedHealthcare denials for specialty cancer drugs through the state's external review process. The key is submitting comprehensive medical documentation that clearly demonstrates why the specific drug is medically necessary and why alternatives aren't appropriate. Don't give up after an initial denial – the state review process is designed to provide independent medical judgment."

When to Escalate

Contact the Pennsylvania Insurance Department if:

  • UnitedHealthcare doesn't follow proper appeal procedures
  • Deadlines aren't met for urgent reviews
  • You need help understanding your appeal rights

Counterforce Health specializes in turning insurance denials into successful appeals by crafting evidence-backed rebuttals that address payer-specific criteria and procedural requirements.

Cost Planning for Renewals

Your Cabometyx costs can change annually, so plan ahead:

What Can Change

  • Formulary tier placement
  • Prior authorization requirements
  • Specialty pharmacy network
  • Copay/coinsurance amounts
  • Manufacturer assistance program terms

Annual Planning Steps

  1. Review plan changes during open enrollment
  2. Verify continued coverage for the new plan year
  3. Re-enroll in manufacturer programs if required
  4. Update PA documentation with current medical records
  5. Budget for potential cost increases

Renewal Reminders

  • Set calendar reminders for PA renewals (typically 12 months)
  • Keep current medical records readily available
  • Monitor for new treatment options or guidelines
  • Stay informed about formulary changes

Conversation Scripts

Calling UnitedHealthcare Member Services

"Hi, I need to verify coverage for Cabometyx, spelled C-A-B-O-M-E-T-Y-X, for my cancer treatment. Can you tell me what tier it's on, what my copay responsibility would be, and whether prior authorization is required? My member ID is [number]."

Requesting Expedited Review

"My oncologist is requesting expedited prior authorization review for Cabometyx because any delay in starting this cancer treatment could seriously jeopardize my health. We have all the required documentation ready to submit immediately."

Peer-to-Peer Request Script (for clinic staff)

"We're requesting a peer-to-peer review for [patient name]'s Cabometyx prior authorization denial. Our oncologist needs to discuss the medical necessity with your medical director. This is an urgent cancer case where treatment delays could affect outcomes."

FAQ

How long does UnitedHealthcare prior authorization take for Cabometyx in Pennsylvania? Standard review is typically 72 hours with complete documentation. Expedited reviews for urgent cases can be completed within 24-48 hours.

What if Cabometyx is not on my UnitedHealthcare formulary? You can request a formulary exception with medical necessity documentation. Your oncologist needs to demonstrate why preferred alternatives aren't appropriate for your specific situation.

Can I use manufacturer copay assistance with UnitedHealthcare? Yes, if you have commercial insurance (not Medicare or Medicaid). However, check if your plan uses copay accumulators that may limit how the assistance counts toward your deductible.

Does step therapy apply to Cabometyx for all cancer types? Step therapy requirements vary by indication. For example, hepatocellular carcinoma typically requires prior sorafenib failure, while some renal cell carcinoma cases may use Cabometyx first-line with nivolumab.

What happens if I move within Pennsylvania or change employers? Your coverage may change significantly. Verify Cabometyx coverage with your new plan immediately and submit new prior authorization if required.

How do I know if my plan is self-funded or fully-insured for appeal purposes? Check your plan documents or ask HR. Self-funded plans typically say "administered by UnitedHealthcare" while fully-insured plans say "insured by UnitedHealthcare."

Can I request an expedited appeal in Pennsylvania? Yes, both UnitedHealthcare internal appeals and Pennsylvania external reviews offer expedited options when delays would jeopardize your health or ability to regain maximum function.

What if my oncologist isn't familiar with UnitedHealthcare's requirements? Share UnitedHealthcare's Cabometyx coverage policy with your provider and consider working with a patient advocacy service that specializes in insurance appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with UnitedHealthcare and consult with your healthcare team about treatment decisions. For personalized assistance with insurance appeals and prior authorization, consider consulting with patient advocacy services that specialize in coverage issues.

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