By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Aetna CVS Health in Georgia: Appeals, Alternatives & Timeline

Answer Box: Getting Cometriq (Cabozantinib) Covered by Aetna CVS Health in Georgia

Cometriq (cabozantinib capsules) requires prior authorization from Aetna CVS Health for metastatic medullary thyroid carcinoma. Submit your PA request through the CVS Caremark provider portal with medical necessity documentation, recent imaging showing progression, and prior therapy records. Standard decisions take 72 hours; urgent requests are processed within 2 business days. If denied, you have 180 days to appeal internally, then 60 days for Georgia's external review through the Department of Insurance.

First step today: Have your oncologist gather your MTC diagnosis documentation, imaging reports, and records of any prior treatments to submit the initial PA request.

Table of Contents

  1. When Formulary Alternatives Make Sense
  2. Typical Alternatives for Medullary Thyroid Cancer
  3. Pros and Cons Overview
  4. Exception Strategy: When to Request Cometriq
  5. Switching Logistics and Coordination
  6. Re-trying for Cometriq Later
  7. Appeals Playbook for Georgia
  8. Common Denial Reasons & Fixes
  9. Costs & Savings Options
  10. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Cometriq requests CVS Caremark formulary Aetna Specialty Drug List
Diagnosis Code C75.0 (medullary thyroid carcinoma) Medical records FDA labeling
Formulation Capsules only (not Cabometyx tablets) Prescription FDA Access Data
Step Therapy Often requires Vandetanib trial first PA criteria CVS Caremark policy
Appeal Deadline 180 days (internal), 60 days (external) Denial letter Georgia DOI regulations

When Formulary Alternatives Make Sense

Before pursuing an exception for Cometriq, it's worth understanding when alternatives might be appropriate. Aetna CVS Health typically requires step therapy for advanced medullary thyroid carcinoma, meaning you'll need to try their preferred option first unless there's a documented contraindication.

Alternatives make sense when:

  • You haven't tried other FDA-approved MTC treatments
  • Cost is a significant concern (some alternatives may have lower copays)
  • Your tumor has specific genetic markers that respond well to other agents
  • You're experiencing intolerable side effects from current therapy

Skip alternatives and go straight to Cometriq when:

  • You've already failed or can't tolerate Vandetanib
  • Your oncologist documents specific clinical reasons why alternatives won't work
  • You have contraindications to the preferred agents
Tip: Georgia patients often have better success getting specialty drugs approved when they can show they've worked through the insurer's preferred treatment pathway first.

Typical Alternatives for Medullary Thyroid Cancer

First-Line Options (Usually Preferred by Aetna CVS Health)

Vandetanib (Caprelsa)

  • FDA-approved specifically for symptomatic or progressive metastatic MTC
  • Often the required first step in Aetna's step therapy protocol
  • Available through CVS Specialty Pharmacy
  • Requires cardiac monitoring (QT prolongation risk)

Second-Line Considerations

Selective RET Inhibitors

  • Selpercatinib (Retevmo) and pralsetinib (Gavreto) for RET-mutated tumors
  • May be preferred over multikinase inhibitors when RET mutations are present
  • Typically require genetic testing documentation

Clinical Trials

  • Often covered when standard therapies have failed
  • ClinicalTrials.gov lists active MTC studies in Georgia

At Counterforce Health, we've seen that patients who understand their insurer's preferred treatment sequence often navigate the approval process more smoothly. The platform helps identify exactly which alternatives your plan requires and builds targeted appeals when exceptions are needed.

Pros and Cons Overview

Vandetanib (Caprelsa) - Typical First Choice

Pros:

  • FDA-approved for MTC with established efficacy data
  • Usually covered with standard PA approval
  • Extensive safety profile and monitoring guidelines

Cons:

  • Requires regular cardiac monitoring (ECGs, electrolytes)
  • Can cause diarrhea, rash, and fatigue
  • Drug interactions with QT-prolonging medications

Cometriq (Cabozantinib) - When Alternatives Fail

Pros:

  • Proven efficacy in progressive MTC
  • Different side effect profile than vandetanib
  • May work when other agents fail

Cons:

  • Requires exception request if step therapy applies
  • Higher out-of-pocket costs on some plans
  • Hand-foot syndrome and diarrhea common
From our advocates: We've found that patients who document their experience with first-line therapy thoroughly—including specific side effects, dose reductions, and quality of life impacts—have stronger cases for exceptions to their preferred agents. This documentation becomes crucial for both internal appeals and Georgia's external review process.

Exception Strategy: When to Request Cometriq

Medical Necessity Documentation

Your oncologist should include:

  1. Diagnosis confirmation with pathology reports showing medullary thyroid carcinoma
  2. Disease progression documented by imaging (RECIST criteria preferred)
  3. Prior therapy failures or contraindications to preferred agents
  4. Clinical rationale for cabozantinib specifically

Supporting Evidence That Helps

  • Recent CT or MRI showing measurable disease progression
  • Calcitonin and CEA tumor marker trends
  • Documentation of symptoms impacting quality of life
  • Genetic testing results (RET mutations, if applicable)
  • Previous treatment timeline with specific agents, doses, and outcomes

When to Submit the Exception

Submit immediately if:

  • Patient has documented intolerance to vandetanib
  • Contraindications exist to preferred agents
  • Disease is rapidly progressing and delay risks patient safety

Consider alternatives first if:

  • This is the initial MTC treatment request
  • No prior systemic therapy has been attempted
  • Cost considerations are primary concern

Switching Logistics and Coordination

Provider Coordination

  1. Schedule transition visit with your oncologist before switching
  2. Review drug interactions between current and new medications
  3. Plan monitoring schedule for new agent side effects
  4. Coordinate with CVS Specialty Pharmacy for delivery timing

Insurance Transition

  • Notify Aetna CVS Health of planned switch 2-3 weeks in advance
  • Ensure new PA is approved before stopping current therapy
  • Verify copay assistance transfers to new medication
  • Confirm specialty pharmacy network coverage

Pharmacy Logistics

CVS Specialty Pharmacy typically handles Cometriq distribution for Aetna members. They'll coordinate:

  • Prior authorization submission
  • Insurance verification
  • Copay assistance enrollment
  • Home delivery scheduling

Re-trying for Cometriq Later

What to Document During Alternative Trials

Keep detailed records of:

  • Specific side effects with dates and severity grades
  • Dose modifications and reasons for changes
  • Efficacy measures including imaging and tumor markers
  • Quality of life impacts affecting daily activities
  • Duration of therapy before discontinuation

When to Resubmit

Consider resubmitting for Cometriq when:

  • Alternative therapy shows progression after 3+ months
  • Intolerable side effects develop with preferred agents
  • New clinical data supports cabozantinib use
  • Patient's performance status changes

Strengthening Your Case

  • Reference specific PA denial reasons from first attempt
  • Include peer-reviewed studies supporting cabozantinib in your clinical situation
  • Document failed alternatives with objective measures
  • Consider requesting peer-to-peer review with Aetna medical director

Appeals Playbook for Georgia

Internal Appeals (First Level)

Timeline: File within 180 days of denial Decision time: 15 days (non-urgent), 72 hours (urgent) How to file: Aetna member portal or call member services

Required documents:

  • Original denial letter
  • Medical necessity letter from oncologist
  • Supporting clinical documentation
  • Completed appeal form

Georgia External Review (Final Level)

Timeline: File within 60 days of final internal denial Decision time: 30-45 days (standard), 72 hours (expedited) Cost: Free to patient

How to file: Submit request to Georgia Department of Insurance

The external review process in Georgia is particularly powerful for specialty drug denials. Independent physicians review your case and make binding decisions that Aetna must follow.

Common Denial Reasons & Fixes

Denial Reason How to Fix Documents Needed
"Not FDA-approved for indication" Verify MTC diagnosis in records Pathology report, ICD-10 C75.0
"Step therapy required" Document vandetanib failure/intolerance Treatment records, side effect log
"Experimental/investigational" Cite FDA approval and guidelines FDA labeling, NCCN guidelines
"Tablet/capsule confusion" Specify Cometriq capsules for MTC Corrected prescription
"Insufficient documentation" Submit complete PA packet All required clinical notes

Costs & Savings Options

Manufacturer Support

  • Exelixis Patient Support Program: Copay assistance and free drug programs
  • Eligibility: Most commercial insurance patients qualify
  • Savings: Up to $25,000/year in copay assistance

Foundation Grants

  • CancerCare Co-Payment Assistance Foundation
  • Patient Advocate Foundation Co-Pay Relief Program
  • Leukemia & Lymphoma Society Patient Financial Aid

Georgia-Specific Resources

  • Georgia Cancer Info Link: Patient navigation services
  • Georgians for a Healthy Future: Insurance assistance and advocacy

When dealing with complex insurance approvals like Cometriq coverage, Counterforce Health helps patients and providers turn denials into successful appeals by analyzing the specific denial reasons and crafting targeted, evidence-based responses that address Aetna's exact criteria.

FAQ

How long does Aetna CVS Health prior authorization take for Cometriq in Georgia? Standard requests are decided within 72 hours. Urgent requests are processed within 2 business days when clinical urgency is documented.

What if Cometriq is non-formulary on my Aetna plan? Non-formulary drugs can still be covered through formulary exceptions. Submit medical necessity documentation showing why formulary alternatives won't work for your specific situation.

Can I request an expedited appeal if Aetna denies Cometriq? Yes, if your oncologist certifies that delay would seriously jeopardize your health. Expedited appeals are decided within 72 hours.

Does step therapy apply if I failed treatments outside Georgia? Treatment history from other states counts toward step therapy requirements. Include complete medical records from previous providers.

What's the difference between Cometriq and Cabometyx for insurance purposes? Cometriq (capsules) is approved for medullary thyroid cancer, while Cabometyx (tablets) is for kidney and liver cancers. These are not interchangeable formulations.

How do I find out my specific Aetna formulary tier for Cometriq? Check your plan's formulary document or call CVS Caremark member services. The tier determines your copay amount.

Can I appeal to Georgia if I have an employer plan? Most employer plans are subject to federal ERISA rules, not state external review. However, some state-regulated employer plans may qualify for Georgia's external review process.

What happens if both internal appeals and Georgia external review deny coverage? You may have legal options depending on your plan type and circumstances. Consider consulting with a healthcare attorney or patient advocacy organization.

Sources & Further Reading

This article is for informational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For assistance with appeals and prior authorizations, contact your plan's member services or consider working with a patient advocacy organization.

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