By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Blue Cross Blue Shield Michigan: Complete Guide to Prior Authorization, Appeals, and Coding

Answer Box: Getting Cometriq Covered by BCBS Michigan

Cometriq (cabozantinib) is covered by Blue Cross Blue Shield of Michigan with prior authorization for metastatic medullary thyroid carcinoma. Key requirements: ICD-10 code C73, documented MTC diagnosis, and electronic PA submission via CoverMyMeds or similar platform. If denied, you have 127 days to file an external review with Michigan DIFS. Start today: Have your oncologist submit a PA request with clinical notes proving MTC diagnosis and medical necessity.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Cometriq (cabozantinib) capsules are exclusively covered under the pharmacy benefit by Blue Cross Blue Shield of Michigan. Unlike injectable cancer drugs that might be covered under the medical benefit, oral oncology medications like Cometriq require specialty pharmacy dispensing and prior authorization through pharmacy channels.

Key Differences:

  • Medical Benefit: Injectable/infused drugs with HCPCS J-codes
  • Pharmacy Benefit: Oral medications with NDC codes, requiring PA through pharmacy channels

Important: Cometriq has no permanent HCPCS J-code and should never be billed under medical benefit claims. Attempts to use temporary codes like J9999 will result in denial.

ICD-10 Mapping for Medullary Thyroid Carcinoma

The primary diagnosis code for medullary thyroid carcinoma is C73 (malignant neoplasm of thyroid gland). For insurance approval, your documentation must clearly establish the MTC diagnosis.

Required Documentation:

  • Primary Code: C73
  • Supporting Evidence: Two or more serum calcitonin measurements after surgery
  • Surgical History: Total thyroidectomy (codes P4552, P4561) or lobectomy (codes P4551, P4553, P4554)

Documentation Words That Support Coding:

  • "Medullary thyroid carcinoma"
  • "Elevated calcitonin levels"
  • "C-cell hyperplasia"
  • "Progressive disease"
  • "Metastatic medullary thyroid cancer"
Note: For metastatic disease, additional codes may be needed to specify metastatic sites (e.g., C78.00 for secondary malignant neoplasm of unspecified lung).

Product Coding: NDC and Billing Requirements

Cometriq uses specific NDC codes that must match the exact formulation dispensed. Critical: Cometriq capsules are NOT interchangeable with Cabometyx tablets, even though both contain cabozantinib.

Cometriq NDC Codes:

  • Daily blister cards: Various strengths (60mg, 100mg, 140mg daily doses)
  • 28-day supply packaging
  • Example NDC: 42388-0110-28 (verify current codes with pharmacy)

Billing Requirements:

  • Use exact NDC matching dispensed strength
  • Submit via specialty pharmacy (typically Walgreens Specialty)
  • Include days supply (usually 28 days)
  • Attach prior authorization approval

Clean Prior Authorization Request

A successful PA request to BCBS Michigan must include specific clinical elements and follow electronic submission requirements.

Required Components:

1. Patient Information

  • BCBS Michigan member ID
  • Date of birth
  • Prescribing physician NPI

2. Clinical Documentation

  • ICD-10 code C73
  • Pathology report confirming MTC
  • Calcitonin levels (pre and post-surgery)
  • Imaging showing disease progression

3. Treatment History

  • Previous therapies attempted (if any)
  • Contraindications to alternatives
  • Failure or intolerance documentation

4. Prescription Details

  • Cometriq capsules (specify NOT Cabometyx tablets)
  • Exact dosing regimen
  • Duration of therapy

Electronic Submission Requirements

Michigan law (MCL 500.2212e) requires electronic PA submission as of June 2023. Use platforms like:

  • CoverMyMeds
  • Surescripts
  • BCBS Michigan provider portal

Common Coding Pitfalls to Avoid

Pitfall Consequence Solution
Using Cabometyx NDC instead of Cometriq Automatic denial - wrong indication Verify capsule formulation NDC
Missing ICD-10 code C73 "Not medically necessary" denial Include primary thyroid cancer code
Incomplete calcitonin documentation Insufficient evidence of MTC Provide pre/post-surgery levels
Fax submission without certification Rejection under Michigan ePA law Use electronic platforms only
Wrong specialty pharmacy Claim processing delays Confirm Walgreens Specialty or approved network

BCBS Michigan Verification Process

Before submitting your PA request, verify current requirements through official BCBS Michigan resources.

Verification Steps:

  1. Check formulary status via BCBS Michigan Clinical Drug List
  2. Confirm PA requirements through provider portal
  3. Verify specialty pharmacy network (typically Walgreens Specialty: 1-866-515-1355)
  4. Review step therapy requirements for your patient's specific plan
Tip: BCBS Michigan updates formularies regularly. Always check the most current version before submitting requests.

Appeals Process in Michigan

If your Cometriq PA request is denied, Michigan provides robust appeal rights under the Patient's Right to Independent Review Act.

Internal Appeal Process:

  • Timeline: Submit within plan's specified timeframe (typically 60 days)
  • Method: Electronic submission preferred
  • Documentation: Additional clinical evidence, peer-reviewed studies supporting use

External Review with Michigan DIFS:

  • Timeline: 127 days after final internal denial
  • Process: File via Michigan DIFS External Review
  • Decision: Binding determination within 60 days (72 hours for expedited)

Expedited Appeals:

For urgent medical situations, request expedited review with physician letter documenting that delay would "seriously jeopardize life or health."

Contact Michigan DIFS: 877-999-6442

At Counterforce Health, we help patients and clinicians navigate complex prior authorization denials by creating targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that address specific payer criteria, increasing approval rates for specialty medications like Cometriq.

Quick Audit Checklist

Before submitting your Cometriq PA request, verify:

  • ICD-10 code C73 documented
  • Cometriq capsules specified (not Cabometyx tablets)
  • Correct NDC for dispensed strength
  • Electronic submission via approved platform
  • Calcitonin levels included
  • Pathology report attached
  • Previous treatment failures documented (if applicable)
  • Specialty pharmacy confirmed in network
  • Days supply matches prescription (typically 28 days)
  • Prescriber NPI and DEA numbers included

FAQ

How long does BCBS Michigan take to approve Cometriq PA requests? Standard PA decisions are typically made within 72 hours for electronic submissions. Urgent requests can be processed within 24 hours with proper clinical documentation.

What if Cometriq is non-formulary on my BCBS Michigan plan? Request a formulary exception with medical necessity documentation. Include evidence that preferred alternatives are inappropriate due to contraindications or previous failures.

Can I get expedited approval if I'm currently hospitalized? Yes, request expedited PA review with physician attestation that delay would harm your health. BCBS Michigan processes urgent requests within 24-48 hours.

Does step therapy apply to Cometriq for medullary thyroid carcinoma? Step therapy requirements vary by plan. For MTC, alternatives are limited (vandetanib), so step therapy may not apply if contraindications exist.

What happens if I'm denied after internal appeals? You can file an external review with Michigan DIFS within 127 days. The independent medical review is binding and free to patients.

Can my doctor submit the appeal for me? Yes, with your written consent, your physician can file appeals as your authorized representative throughout the process.

From our advocates: We've seen MTC patients successfully appeal Cometriq denials by emphasizing the drug's unique FDA indication specifically for medullary thyroid carcinoma. Unlike other thyroid cancers, MTC doesn't respond to radioactive iodine, making targeted therapies like Cometriq essential. Including this distinction in appeals often helps reviewers understand why alternatives aren't appropriate.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional support with complex prior authorizations and appeals, Counterforce Health provides specialized assistance in turning insurance denials into successful approvals through evidence-based appeal strategies.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.