By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Blue Cross Blue Shield in Ohio: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Cometriq Covered in Ohio

Blue Cross Blue Shield of Ohio (Anthem BCBS OH) requires prior authorization for Cometriq (cabozantinib capsules) for progressive/metastatic medullary thyroid carcinoma. First step: Verify your diagnosis meets criteria (confirmed MTC with progression, no active bleeding/GI issues). Fastest path: Submit PA via Anthem Provider Portal with complete documentation including pathology, imaging, and medical necessity letter. If denied: File internal appeal within 180 days, then external review through Ohio Department of Insurance (1-800-686-1526). Success rates improve significantly with thorough documentation addressing denial reasons.

Table of Contents

  1. Understanding Blue Cross Blue Shield Coverage for Cometriq in Ohio
  2. Prior Authorization Requirements
  3. Common Denial Reasons and How to Fix Them
  4. Step-by-Step Appeal Process
  5. Medical Necessity Letter Checklist
  6. Ohio External Review Process
  7. Cost-Saving Options
  8. Frequently Asked Questions

Understanding Blue Cross Blue Shield Coverage for Cometriq in Ohio

Cometriq (cabozantinib capsules) is a specialty oncology medication approved by the FDA for progressive, metastatic medullary thyroid carcinoma (MTC). In Ohio, Blue Cross Blue Shield (primarily Anthem BCBS OH) covers Cometriq but requires prior authorization and places it on the specialty formulary tier.

Key Coverage Facts:

  • Formulation matters: Only Cometriq capsules are approved for MTC—not Cabometyx tablets
  • Specialty tier placement: Expect higher copays and 30-day supply limits
  • Prior authorization required: No exceptions for emergency fills
  • Initial approval: 12 months with renewal under same criteria

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all MTC indications Anthem PA Form
Formulary Status Specialty tier (check current list) Anthem OH Drug List
Diagnosis Coverage Progressive/metastatic MTC only BCBS Policy
Contraindications No coverage with active bleeding/GI issues FDA Black Box Warnings
Appeals Deadline 180 days from denial (Ohio law) Ohio DOI

Prior Authorization Requirements

Blue Cross Blue Shield of Ohio follows strict criteria for Cometriq coverage. Your oncologist must submit documentation proving medical necessity through the Anthem Provider Portal or by fax.

Required Documentation Checklist

Clinical Information:

  • ✅ Confirmed MTC diagnosis with pathology report
  • ✅ ICD-10 code C73 (malignant neoplasm of thyroid gland)
  • ✅ Staging documentation (progressive/metastatic disease)
  • ✅ Recent imaging showing progression
  • ✅ Serum calcitonin and CEA levels

Treatment History:

  • ✅ Prior therapy attempts and outcomes
  • ✅ Contraindications to other treatments
  • ✅ Performance status assessment
  • ✅ Organ function laboratory results

Prescription Details:

  • ✅ Cometriq capsules specifically (not Cabometyx tablets)
  • ✅ Appropriate dosing (typically 140 mg daily)
  • ✅ Duration of treatment requested
  • ✅ Prescriber attestation of medical necessity
Clinician Corner: Medical Necessity Letter

Your letter should address: (1) MTC diagnosis with staging, (2) disease progression requiring treatment, (3) why Cometriq is appropriate vs. alternatives, (4) patient's ability to tolerate therapy, and (5) treatment goals. Reference the EXAM trial data showing 11.2 months progression-free survival and cite NCCN guidelines supporting cabozantinib as preferred therapy for advanced MTC.

Common Denial Reasons and How to Fix Them

Understanding why Cometriq gets denied helps you build a stronger appeal. Here are the most frequent issues we see:

Denial Reason Fix Strategy Documentation Needed
Wrong formulation prescribed Emphasize Cometriq capsules for MTC FDA labeling showing capsule-specific approval
Missing MTC diagnosis Provide complete pathology CAP synoptic report with calcitonin staining
"Not medically necessary" Document disease progression Recent imaging + elevated tumor markers
Contraindication concerns Address bleeding/GI history Current labs showing stability
Step therapy requirement Show failed prior treatments Treatment timeline with outcomes

Formulation Confusion: A Common Problem

Insurance policies often incorrectly substitute Cabometyx tablets for Cometriq capsules. The EOCCO policy explicitly states that "Cabometyx should not be used for medullary thyroid carcinoma (MTC)." If your denial mentions Cabometyx, immediately appeal citing the FDA's distinct approvals for each formulation.

Step-by-Step Appeal Process

If your initial prior authorization is denied, Ohio law gives you multiple appeal opportunities with Blue Cross Blue Shield before external review.

Internal Appeals Process

Step 1: Review Your Denial Letter

  • Identify the specific denial reason
  • Note the appeal deadline (typically 180 days)
  • Gather your member ID and claim information
  • Contact Counterforce Health if you need help interpreting complex denial language

Step 2: Gather Supporting Evidence

  • Original denial letter (all pages)
  • Complete medical records for 3-6 months
  • Pathology reports confirming MTC
  • Recent imaging studies
  • Laboratory results (calcitonin, CEA)
  • Treatment history documentation

Step 3: Submit Internal Appeal

  • Use Anthem's standard appeal form or write a letter
  • Include physician letter of medical necessity
  • Submit via member portal, fax, or certified mail
  • Keep copies and track submission

Step 4: Request Peer-to-Peer Review

  • Have your oncologist call Anthem utilization management
  • Schedule within 10 business days of denial
  • Prepare talking points addressing denial reasons
  • Follow up with written documentation

Appeals Timeline for Ohio

Appeal Level Filing Deadline Decision Time Next Step
Internal Level 1 180 days from denial 30 days Level 2 or external
Internal Level 2 60 days from Level 1 denial 30 days External review
Expedited Same deadlines 72 hours If urgent medical need
External Review 180 days from final denial 30 days Binding decision

Medical Necessity Letter Checklist

A strong medical necessity letter is often the difference between approval and denial. Here's what your oncologist should include:

Essential Elements

Patient Background:

  • Age, diagnosis date, staging at presentation
  • Family history (important for hereditary MTC)
  • Performance status and overall health

Disease Progression:

  • Timeline of disease advancement
  • Imaging studies showing progression
  • Rising tumor markers (calcitonin, CEA)
  • Symptoms affecting quality of life

Treatment Rationale:

  • Why Cometriq is appropriate for this patient
  • Evidence base from clinical trials
  • Expected benefits and monitoring plan
  • Why alternatives are not suitable

Clinical Guidelines Support:

  • NCCN Category 1 recommendation for cabozantinib in advanced MTC
  • FDA approval based on EXAM trial data
  • ATA guidelines supporting targeted therapy
From Our Advocates

We've seen appeals succeed when physicians clearly explain why the patient needs this specific formulation. One effective approach involves creating a timeline showing disease progression despite other treatments, then citing specific NCCN guidelines that recommend Cometriq as preferred therapy. This combination of patient-specific evidence and guideline support significantly improves approval rates.

Ohio External Review Process

If Blue Cross Blue Shield denies your internal appeals, Ohio law provides an independent external review through the Ohio Department of Insurance.

How External Review Works

Eligibility:

  • Applies to fully insured Blue Cross Blue Shield plans (not self-funded employer plans)
  • Covers denials involving medical judgment or medical necessity
  • Must exhaust internal appeals first

Filing Process:

  1. Contact your insurer to request external review within 180 days
  2. Insurer forwards request to Ohio Department of Insurance
  3. ODI assigns an Independent Review Organization (IRO)
  4. IRO reviews all medical records and makes binding decision

Timeline:

  • Standard review: Decision within 30 days
  • Expedited review: Decision within 72 hours for urgent cases
  • Cost: Up to $25 maximum (often free)

Contact Information:

  • Ohio DOI Consumer Hotline: 1-800-686-1526
  • External Review System: Available through insurance.ohio.gov

The external review decision is binding on Blue Cross Blue Shield—if the IRO approves coverage, your insurer must pay for Cometriq.

Cost-Saving Options

Even with insurance coverage, Cometriq can be expensive. Here are programs that may help reduce your costs:

Manufacturer Support

  • Exelixis Patient Access Program: May provide copay assistance or free drug for eligible patients
  • Income requirements: Typically for households earning up to 400% of federal poverty level
  • Application: Through Exelixis website or by calling their patient support line

Foundation Grants

  • HealthWell Foundation: Grants for cancer patients with insurance
  • Patient Access Network (PAN): Thyroid cancer fund available
  • CancerCare: Financial assistance and copay relief programs

Specialty Pharmacy Options

Blue Cross Blue Shield typically requires specialty pharmacy dispensing for Cometriq. Counterforce Health can help you navigate specialty pharmacy requirements and ensure smooth delivery of your medication.

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Ohio? Standard PA decisions are typically made within 72 hours to 15 business days. Expedited requests (for urgent medical needs) must be decided within 24-72 hours under Ohio regulations.

What if Cometriq is non-formulary on my Blue Cross Blue Shield plan? You can request a formulary exception by demonstrating medical necessity. This requires showing that formulary alternatives are inappropriate, ineffective, or contraindicated for your specific situation.

Can I request an expedited appeal if my condition is worsening? Yes, if your physician certifies that a delay in treatment would seriously jeopardize your health, you can request expedited review at any appeal level. Decisions must be made within 72 hours.

Does step therapy apply if I've failed treatments outside Ohio? Treatment history from other states should count toward step therapy requirements. Provide complete documentation of prior therapies, including dates, dosages, duration, and reasons for discontinuation.

What happens if my employer plan is self-funded? Self-funded plans follow federal ERISA law rather than Ohio insurance regulations. However, many still use similar appeal processes and may voluntarily participate in external review programs.

How much does Cometriq cost without insurance? Cash prices typically range around $18,938 for a 112-capsule monthly supply. This makes insurance coverage or patient assistance programs essential for most patients.

Can I appeal if Blue Cross Blue Shield requires Cabometyx instead of Cometriq? Absolutely. This is a common denial reason that's often overturned on appeal. Emphasize that FDA approval for MTC is specific to Cometriq capsules, and provide clinical evidence showing they're not interchangeable.

What documentation should I keep during the appeals process? Keep copies of all denial letters, appeal submissions, medical records, correspondence, and tracking confirmations. Create a timeline of all communications and maintain both physical and digital copies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance tailored to your situation. For complex appeals, consider working with advocacy services like Counterforce Health that specialize in insurance denials and appeals.

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