By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (cabozantinib) Covered by Blue Cross Blue Shield in New Jersey: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Cometriq Covered in New Jersey

Cometriq (cabozantinib capsules) requires prior authorization from Blue Cross Blue Shield in New Jersey for metastatic medullary thyroid carcinoma. Your oncologist submits the PA electronically with pathology reports, imaging showing progression, and medical necessity documentation. If denied, you have 180 days to appeal internally, then can request external review through New Jersey's IHCAP program administered by Maximus. Start today: Call your Blue Cross member services to confirm your specific plan's formulary status and PA requirements.

Fastest path: Oncologist → Electronic PA submission → Standard review (1-3 days) → If approved, specialty pharmacy fills within 24-48 hours.

Table of Contents

Understanding Your Blue Cross Coverage

Cometriq is typically covered as a Tier 3 specialty medication under Blue Cross Blue Shield plans in New Jersey, including Horizon Blue Cross Blue Shield (the state's largest insurer with ~39% market share). The drug requires dispensing through approved specialty pharmacies and prior authorization for all patients.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all patients Horizon PA Drug List
Formulary Tier Tier 3 (Non-Preferred Brand) Member portal or formulary PDF
Specialty Pharmacy Mandatory for dispensing Horizon Specialty Network
Quantity Limits Typically 30-day supply PA submission form
Step Therapy Generally not required for FDA indication Plan-specific policy
Appeals Deadline 180 days from denial Plan documents
Important: Cometriq capsules are not interchangeable with Cabometyx tablets. Many denials occur when the wrong formulation is requested.

Prior Authorization Requirements

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Staff)
    • Call Blue Cross member services using the number on your insurance card
    • Confirm Cometriq is on formulary and identify your specialty pharmacy network
    • Timeline: 5-10 minutes
  2. Gather Documentation (Clinic Staff)
    • Pathology report confirming medullary thyroid carcinoma (ICD-10: C73)
    • Recent imaging showing metastatic or progressive disease
    • Calcitonin and CEA levels
    • Timeline: 1-2 hours
  3. Submit PA Electronically (Oncologist)
    • Use Availity portal or Blue Cross provider portal
    • Include all required documentation and medical necessity letter
    • Timeline: 30 minutes to submit
  4. PA Review (Blue Cross)
    • Standard review: 1-3 business days
    • Expedited review: 24-72 hours (if medically urgent)
  5. Approval and Fill (Specialty Pharmacy)
    • Pharmacy contacts patient within 24 hours of approval
    • Medication shipped overnight or available for pickup
    • Timeline: 24-48 hours

Required Documentation Checklist

  • Confirmed diagnosis of metastatic medullary thyroid carcinoma
  • Pathology report with specific MTC histology
  • Imaging studies (CT, MRI, or PET) showing metastatic disease
  • Evidence of disease progression (RECIST criteria preferred)
  • Elevated calcitonin and/or CEA levels
  • Documentation of prior thyroidectomy (if applicable)
  • Patient's ECOG performance status
  • Medical necessity letter from oncologist

Common Denial Reasons & How to Fix Them

Denial Reason How to Fix Required Documentation
Wrong formulation requested Emphasize Cometriq capsules (not Cabometyx tablets) FDA approval letter showing capsule-specific indication
Insufficient progression evidence Provide RECIST 1.1 measurements Before/after imaging with radiologist interpretation
Missing pathology confirmation Submit complete pathology report Synoptic report per CAP standards
Off-label use suspected Clarify metastatic MTC diagnosis ICD-10 C73 coding with staging documentation
Prior therapy not documented Detail surgical history and outcomes Operative notes, post-surgical lab trends
From our advocates: We've seen many Cometriq denials reversed simply by resubmitting with the correct formulation specified. Always emphasize "Cometriq capsules for metastatic medullary thyroid carcinoma" in your initial request to avoid automatic substitution with Cabometyx tablets.

Appeals Process: Internal and External

Internal Appeals with Blue Cross

If your initial PA is denied, you have 180 days to file an internal appeal. Blue Cross plans in New Jersey typically offer two levels of internal review.

Level 1 Appeal:

  • Submit within 180 days of denial
  • Include denial letter, additional clinical evidence, and physician letter
  • Decision timeline: 30 days (expedited: 72 hours)
  • Success rate: ~25-30% for specialty medications

Level 2 Appeal:

  • Available if Level 1 is denied
  • Often includes peer-to-peer review option
  • Decision timeline: 30 days
  • Higher success rate when new evidence is presented

Required Appeal Documents

  1. Original denial letter with specific denial codes
  2. Updated medical necessity letter addressing denial reasons
  3. Additional clinical evidence (new imaging, lab results)
  4. Peer-reviewed literature supporting Cometriq use in MTC
  5. FDA prescribing information highlighting MTC indication

New Jersey External Review (IHCAP)

If internal appeals fail, New Jersey offers one of the nation's strongest external review programs through the Independent Health Care Appeals Program (IHCAP), administered by Maximus Federal Services.

IHCAP Process Overview

  • Eligibility: Completed internal appeals (or unable to due to urgency)
  • Deadline: 120 days (4 months) from final internal denial
  • Cost: $25 fee (waivable for financial hardship)
  • Decision timeline: 45 days standard, 72 hours expedited
  • Success rate: ~50% of external appeals favor consumers

How to File External Review

  1. Register online at njihcap.maximus.com
  2. Complete required forms:
    • Consent to Representation form
    • External review application
  3. Submit documentation:
    • All internal denial letters
    • Complete medical records
    • Supporting clinical literature
  4. Pay $25 fee (or request waiver)

Contact Information:

Note: External review decisions are binding on your insurance company. If the independent physicians determine Cometriq is medically necessary, Blue Cross must cover it.

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your oncologist's letter should address these key elements:

Patient Summary:

  • Age, diagnosis date, and current stage
  • RET mutation status (if tested)
  • Performance status (ECOG score)

Clinical Evidence:

  • Pathology confirmation of MTC
  • Imaging demonstrating metastatic disease
  • Evidence of progression per RECIST 1.1 criteria
  • Current calcitonin and CEA levels

Treatment History:

  • Prior surgical interventions and outcomes
  • Previous systemic therapies (if any)
  • Reasons other treatments are inappropriate

Guideline Support:

  • Reference NCCN Thyroid Carcinoma Guidelines
  • Cite FDA approval for progressive, metastatic MTC
  • Include relevant clinical trial data (EXAM study)

Monitoring Plan:

  • Planned follow-up schedule
  • Adverse event monitoring protocol
  • Response assessment timeline

Supporting Evidence Sources

  • NCCN Guidelines: Category 1 recommendation for cabozantinib in advanced MTC
  • FDA Label: Approved for progressive, metastatic medullary thyroid carcinoma
  • EXAM Trial: Phase III study demonstrating progression-free survival benefit
  • Clinical Practice: Standard of care for progressive MTC post-surgery

Cost and Financial Assistance

Monthly Cost Breakdown

  • Cash price: ~$18,938 for 112 capsules (30-day supply)
  • Blue Cross copay: Varies by plan (typically 20-50% coinsurance for Tier 3)
  • Annual out-of-pocket maximum: Check your specific plan documents

Financial Assistance Options

Exelixis Patient Support Programs:

  • EASE Program: Copay assistance up to $25/month
  • Patient Access Program: Free drug for qualified patients (up to 400% Federal Poverty Level)
  • Contact: 1-855-500-3273 or Cometriq.com

Additional Resources:

  • CancerCare Financial Assistance Program
  • Patient Advocate Foundation Co-Pay Relief Program
  • New Jersey pharmaceutical assistance programs

Scripts and Templates

Patient Phone Script for Blue Cross

"Hi, I'm calling to check prior authorization status for Cometriq capsules. My member ID is [number]. My doctor submitted a PA request on [date] for metastatic medullary thyroid carcinoma. Can you confirm if this has been reviewed and what the status is?"

Clinic Staff PA Submission Script

"Requesting prior authorization for Cometriq (cabozantinib) capsules - NOT Cabometyx tablets - for patient with progressive metastatic medullary thyroid carcinoma (ICD-10 C73). Patient meets FDA-approved indication with documented progression on imaging. All supporting documentation attached."

Peer-to-Peer Request Template

"I'm requesting a peer-to-peer review for [patient name] regarding denied Cometriq coverage. This patient has progressive metastatic MTC with clear progression on imaging and elevated tumor markers. I can discuss the clinical rationale and guideline support at your earliest convenience."

Frequently Asked Questions

How long does Blue Cross PA take in New Jersey? Standard review is 1-3 business days. Expedited review (for urgent medical situations) is completed within 24-72 hours.

What if Cometriq is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Success rates are higher when you demonstrate failed alternatives or contraindications.

Can I request an expedited appeal? Yes, if waiting for standard review would jeopardize your health or ability to regain function. Document the urgency in your appeal request.

Does step therapy apply to Cometriq? Generally not for the FDA-approved MTC indication, but some plans may require documentation of surgical failure or disease progression.

What happens if all appeals fail? Consider clinical trials, compassionate use programs, or switching to an alternative Blue Cross plan during open enrollment.

How do I find in-network specialty pharmacies? Check your Blue Cross member portal or call the specialty pharmacy number on your insurance card. Horizon BCBS has a specific specialty pharmacy network.

Can my doctor help with appeals? Yes, providers can file external appeals on your behalf with your written consent. Many oncology practices have dedicated staff for insurance appeals.

Are there alternatives if Cometriq isn't covered? Vandetanib is another FDA-approved option for MTC. For RET-positive patients, selpercatinib or pralsetinib may be alternatives.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed, payer-specific strategies. Our platform analyzes denial letters and plan policies to create targeted rebuttals that align with each insurer's own criteria. Learn more about our coverage advocacy services.

When navigating complex prior authorization requirements like those for Cometriq, having expert guidance can make the difference between coverage and costly delays. Counterforce Health specializes in transforming insurance obstacles into approved treatments through systematic appeals processes.

Sources & Further Reading

This article is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and procedures may change; verify current requirements with your insurer.

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