By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (cabozantinib) Covered by Blue Cross Blue Shield of Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Cometriq Covered in Texas

Blue Cross Blue Shield of Texas (BCBSTX) covers Cometriq (cabozantinib) capsules for metastatic medullary thyroid carcinoma with prior authorization. The fastest path to approval: (1) Confirm your exact BCBSTX plan and verify Cometriq is on your formulary with PA status, (2) Have your oncologist submit a PA request via the Prime Therapeutics portal or fax with complete MTC documentation, and (3) If denied, file an internal appeal within 180 days. Start today by calling the number on your BCBSTX ID card to confirm your specific formulary and PA requirements.

Table of Contents

BCBSTX Policy Overview

Blue Cross Blue Shield of Texas operates multiple plan types with varying coverage rules. For 2024-2025, Cometriq appears on BCBSTX formularies as a preferred drug with prior authorization (PA) across commercial, Marketplace, and Medicare plans.

Plan Types and Coverage

  • Commercial employer plans: Most common BCBSTX coverage; uses Prime Therapeutics for pharmacy benefits
  • Health Insurance Marketplace: Individual and small group plans with 4-tier or 6-tier formularies
  • Medicare Part D: BCBSTX MedicareRx plans follow federal Part D rules
  • STAR Medicaid: Texas Medicaid managed care with separate appeal processes

Key Point: Cometriq (cabozantinib capsules) is specifically approved for medullary thyroid carcinoma, while Cabometyx (cabozantinib tablets) is not. Using the wrong formulation is a common denial reason that can often be corrected on appeal.

Medical Necessity Requirements

BCBSTX follows standard Blue Cross policies for Cometriq coverage. Based on national Blue Cross guidelines, medical necessity requires:

Primary Criteria

  • Confirmed diagnosis: Metastatic or unresectable medullary thyroid carcinoma (ICD-10: C73)
  • Disease progression: Evidence of progressive or advanced disease via imaging or clinical markers
  • Adult patient: Age 18 years or older
  • Specialist prescriber: Oncologist or endocrinologist with experience treating thyroid malignancies
  • Safety screening: No active bleeding, GI perforation, or uncontrolled hypertension

Documentation Standards

Your medical records must include:

  • Pathology report confirming medullary thyroid carcinoma
  • Recent imaging showing metastatic or progressive disease
  • Elevated calcitonin and/or CEA levels
  • Treatment history and prior therapy outcomes
  • Current performance status (ECOG score)
Tip: The College of American Pathologists requires synoptic reporting for thyroid cancers, including histologic type, pTNM staging, and margin status. Ensure your pathology report meets these standards.

Step Therapy and Exceptions

Unlike many oncology drugs, Cometriq typically doesn't require step therapy for its FDA-approved indication (metastatic MTC) because few alternatives exist for this rare cancer. However, BCBSTX may require documentation of:

  • Prior surgical treatment: Total thyroidectomy or lobectomy when appropriate
  • Consideration of clinical trials: If available and suitable
  • Evaluation of other systemic options: Such as vandetanib, if clinically appropriate

Medical Exception Pathways

If step therapy is required, exceptions may be granted for:

  • Contraindications: Medical reasons why alternatives can't be used
  • Prior failures: Documented lack of efficacy or intolerance to required therapies
  • Clinical urgency: Rapidly progressive disease requiring immediate treatment

Quantity Limits and Renewal

BCBSTX enforces quantity limits for Cometriq: 1 carton per 28 days for the 100-dose kit (80 mg + 20 mg capsules).

Coverage at a Glance

Requirement What It Means Source
Prior Authorization Required for all BCBSTX plans Performance Formulary 2024
Quantity Limit 1 carton (100 doses) per 28 days Dispensing Limits Guide
Specialty Drug Must use in-network specialty pharmacy Plan documents
Renewal Period Typically 6-12 months Standard oncology PA policies

Renewal Requirements

PA renewals typically require:

  • Provider attestation of continued clinical benefit
  • Updated imaging or tumor markers showing stable or responding disease
  • Tolerance assessment and toxicity management plan
  • Confirmation that treatment goals are being met

Required Diagnostics and Documentation

For a successful PA, include comprehensive diagnostic evidence:

Essential Lab Values

  • Calcitonin levels: Elevated basal serum calcitonin (>100 pg/mL highly suggestive of MTC)
  • CEA levels: Often elevated in medullary thyroid carcinoma
  • Complete blood count: Baseline values for monitoring
  • Comprehensive metabolic panel: Liver and kidney function

Imaging Requirements

  • Neck ultrasound: Initial assessment of thyroid and lymph nodes
  • CT neck/chest/abdomen-pelvis: Staging for local and distant disease
  • Additional imaging: MRI or PET/CT as clinically indicated for metastatic disease

Genetic Testing

  • RET mutation analysis: Essential for all MTC cases to identify hereditary forms
  • Family screening: If hereditary MTC (MEN2A, MEN2B, FMTC) is identified

Specialty Pharmacy Requirements

Cometriq is classified as a specialty medication and must be dispensed through BCBSTX's in-network specialty pharmacy network. While specific network details weren't found in available documents, typical requirements include:

  • Designated specialty pharmacies only: Cannot be filled at retail pharmacies
  • Prior authorization must be approved before dispensing
  • Patient education and monitoring: Specialty pharmacies provide enhanced services
  • Coordination with providers: Direct communication about side effects and adherence

Contact the number on your BCBSTX ID card to confirm your plan's specialty pharmacy network and requirements.

Evidence to Support Your Case

Strengthen your PA request with evidence-based documentation:

Clinical Guidelines

  • FDA prescribing information: Cometriq is specifically approved for metastatic MTC
  • NCCN Guidelines: Include cabozantinib as a systemic therapy option for advanced MTC
  • ATA Guidelines: American Thyroid Association recommendations for MTC treatment

Peer-Reviewed Evidence

Reference key studies supporting Cometriq's efficacy:

  • Phase III clinical trials demonstrating progression-free survival benefit
  • Real-world evidence studies in MTC populations
  • Safety and tolerability data relevant to your patient's profile

Sample Medical Necessity Letter

Here's a template structure for your oncologist's PA request:

Patient Demographics and Diagnosis This [age]-year-old patient has been diagnosed with metastatic medullary thyroid carcinoma (ICD-10: C73) confirmed by [pathology report date] showing [specific pathologic findings].

Disease Status and Progression Recent imaging dated [date] demonstrates [specific findings indicating metastatic/progressive disease]. Tumor markers include calcitonin [value] and CEA [value], both elevated and consistent with active MTC.

Treatment History The patient underwent [surgical intervention] on [date]. [Describe any prior systemic therapies, outcomes, and reasons for discontinuation if applicable.]

Medical Necessity for Cometriq Cometriq (cabozantinib capsules) is FDA-approved specifically for metastatic medullary thyroid carcinoma and represents standard-of-care therapy for this indication. The patient meets all criteria for treatment and has no contraindications. Treatment goals include disease stabilization, symptom control, and preservation of quality of life.

Common Denial Reasons and Fixes

Denial Reason How to Fix Required Documentation
Wrong formulation (Cabometyx vs Cometriq) Resubmit with correct drug name New prescription specifying "Cometriq capsules"
Insufficient diagnosis documentation Provide complete pathology report Synoptic pathology report per CAP standards
Missing progression evidence Submit recent imaging CT scans, tumor markers, clinical notes
Non-formulary status Request formulary exception Medical necessity letter with alternatives comparison
Off-label use concern Clarify FDA-approved indication FDA prescribing information, diagnosis confirmation

Texas Appeals Process

If your Cometriq PA is denied, Texas law provides strong appeal rights:

Internal Appeals

  • Timeline: File within 180 days of denial notice (TRS plans) or 60 days (STAR Medicaid)
  • Process: Submit written appeal or call Customer Advocate at 1-888-657-6061
  • Pharmacy appeals: Mail to Prime Therapeutics Appeals, 2900 Ames Crossing Road, Eagan, MN 55121; fax 1-855-212-8110
  • Decision timeline: 30-60 days for standard review, 72 hours for expedited

External Review

If internal appeal fails:

When to Request Expedited Review

Request expedited appeals if:

  • Delay would jeopardize your health
  • Disease is rapidly progressing
  • Current treatment is failing

Counterforce Health helps patients navigate complex insurance appeals for specialty drugs like Cometriq. Our platform analyzes denial letters and creates targeted, evidence-based appeals that address payer-specific requirements. By combining clinical documentation with payer policy knowledge, we help convert denials into approvals while tracking all deadlines and procedural requirements. Visit Counterforce Health to learn how our approach can strengthen your appeal.

Costs and Patient Support

Manufacturer Support

Exelixis Access Services (EASE) provides:

  • Prior authorization assistance
  • Copay assistance for eligible commercial patients (potentially $0/month)
  • Patient assistance programs for uninsured/underinsured patients
  • Reimbursement support and appeals assistance

State Resources

  • Texas Department of Insurance: Consumer hotline 1-800-252-3439 for insurance questions
  • Office of Public Insurance Counsel (OPIC): Help line 1-877-611-6742 for appeals guidance
  • Disability Rights Texas: Assistance with insurance appeals and advocacy

FAQ

How long does BCBSTX prior authorization take? Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests are processed within 24-72 hours.

What if Cometriq isn't on my formulary? You can request a formulary exception by demonstrating medical necessity and lack of suitable alternatives. Include comparative effectiveness data and contraindications to formulary options.

Can I appeal if I live in Texas but have an out-of-state BCBS plan? Appeal rights depend on your specific plan's state of regulation. Contact your plan directly to understand applicable appeal processes and timelines.

Does step therapy apply to Cometriq for MTC? Typically no, since Cometriq is FDA-approved for MTC and few alternatives exist. However, plans may require documentation of surgical evaluation or consideration of clinical trials.

What's the difference between Cometriq and Cabometyx? Both contain cabozantinib but have different formulations and FDA approvals. Cometriq capsules are approved for MTC; Cabometyx tablets are not. Using the wrong formulation often leads to denial.

How much does Cometriq cost without insurance? Cash prices typically range around $18,938 for a 112-capsule "140 mg daily-dose" pack, making insurance coverage crucial for most patients.

This article is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For additional help with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

Sources & Further Reading

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