By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Cigna in New Jersey: Prior Authorization Forms, Appeals, and Timeline

Answer Box: Getting Cometriq Covered by Cigna in New Jersey

Cometriq (cabozantinib) requires prior authorization from Cigna in New Jersey for metastatic medullary thyroid carcinoma. The fastest path to approval: (1) Have your oncologist submit complete PA documentation including pathology confirming MTC diagnosis and ICD-10 code C73, (2) Ensure prescription specifies Cometriq capsules (not Cabometyx tablets), and (3) Use a Cigna-approved specialty pharmacy. If denied, you have 180 days to appeal internally, then can pursue external review through New Jersey's IHCAP program administered by Maximus Federal Services within another 180 days.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. If You Need to Provide Additional Information
  7. If Your Request Is Denied: Appeals Process
  8. Renewal and Re-Authorization
  9. Cost Assistance and Financial Support
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This guide helps patients with metastatic medullary thyroid carcinoma (MTC) and their healthcare teams navigate Cigna's prior authorization process for Cometriq (cabozantinib) in New Jersey. We'll walk through every step from initial submission to appeals, including New Jersey's specific external review rights.

Who this helps:

  • Patients prescribed Cometriq for metastatic MTC
  • Oncology teams managing PA submissions
  • Caregivers advocating for coverage
  • Anyone facing a Cigna denial in New Jersey

Before You Start: Verify Your Coverage

Check Your Plan Details

Call Cigna member services (number on your insurance card) to confirm:

  • Your plan covers specialty oncology drugs
  • Cometriq's formulary tier (typically Tier 4 or 5)
  • Whether you need a specialty pharmacy
  • Your annual out-of-pocket maximum

Confirm Network Status

Ensure your oncologist is in-network with Cigna. Out-of-network providers face additional hurdles and may require different forms.

Understand the Formulation Requirement

Critical: Cometriq capsules are the only FDA-approved cabozantinib formulation for metastatic MTC. Prescribing Cabometyx tablets instead will result in automatic denial.

Gather Required Documentation

Medical Documentation Checklist

Diagnosis Requirements:

  • Pathology report confirming medullary thyroid carcinoma
  • ICD-10 code C73 with explicit mention of "medullary" subtype
  • Staging information showing metastatic disease

Treatment History:

  • Complete list of prior therapies (surgery, radiation, systemic treatments)
  • Documentation of disease progression
  • Evidence that curative surgery is not possible

Clinical Notes:

  • Current performance status
  • Treatment goals and expected outcomes
  • Contraindications to alternative therapies

Required Forms

Primary Form: Cigna Oncology - Cometriq Prior Authorization Form (verify current version with Cigna)

Supporting Documents:

  • Prescriber attestation of medical necessity
  • Recent imaging studies showing progression
  • Laboratory results (calcitonin levels if available)

Submit Your Prior Authorization Request

Submission Methods

For Providers:

  • Cigna provider portal (preferred method)
  • Fax: Confirm current PA fax number through Cigna provider services
  • Phone: 1-800-Cigna-24 for urgent requests

Required Elements in Your Submission:

  1. Completed PA form with all sections
  2. Clinical documentation package
  3. Prescription specifying "Cometriq capsules"
  4. Patient demographics and insurance information

Specialty Pharmacy Coordination

Cometriq must be dispensed through a Cigna-approved specialty pharmacy, typically Express Scripts/Accredo. Coordinate with the pharmacy early in the process.

Follow-Up and Timeline Expectations

New Jersey Timeline Requirements

Under New Jersey's Enhanced Transparency in Prior Authorization Act:

  • Standard requests: 72 hours for Cigna response
  • Urgent requests: 24 hours for response
  • Automatic approval: If Cigna misses deadlines

Follow-Up Best Practices

Day 3 (for standard requests): Call Cigna to confirm receipt and get reference number Day 5: Follow up if no decision received Weekly: Continue follow-up until resolution

Sample Call Script: "I'm calling to check on prior authorization request #[reference number] for Cometriq capsules for my patient with metastatic medullary thyroid carcinoma. What's the current status and expected timeline?"

If You Need to Provide Additional Information

Common Information Requests

Medical Necessity Questions:

  • Provide detailed progression documentation
  • Include NCCN guideline citations supporting Cometriq use
  • Emphasize FDA-approved indication for metastatic MTC

Clinical Clarifications:

  • Prior therapy failures and intolerances
  • Contraindications to alternative treatments
  • Expected treatment duration and monitoring plan

Response Timeline

You typically have 5 business days to submit additional information. Submit promptly to avoid delays.

If Your Request Is Denied: Appeals Process

Internal Appeals (Required First Step)

Level 1 Appeal:

  • Deadline: 180 days from denial notice
  • Cigna response time: 30 days (standard), 72 hours (urgent)
  • How to file: Cigna member portal or call member services

Level 2 Appeal:

  • Deadline: 60 days from Level 1 denial
  • Review: Independent physician in same specialty
  • Response time: Same as Level 1

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Wrong formulation prescribed Correct prescription to Cometriq capsules; resubmit
Insufficient medical necessity Provide detailed progression notes and NCCN guidelines
Missing prior therapy documentation Submit complete treatment history with outcomes
Non-formulary status Request formulary exception with clinical justification

External Review Through IHCAP

If both internal appeals are denied, New Jersey residents can pursue external review:

New Jersey's Independent Health Care Appeals Program (IHCAP):

  • Administered by: Maximus Federal Services
  • Deadline: 180 days from final internal denial
  • Contact: 1-888-393-1062
  • Timeline: 45 days for standard review
  • Cost: Free to patients
  • Decision: Binding on Cigna

Required for IHCAP:

  • Completed internal appeals
  • Copy of final denial letter
  • Medical records supporting necessity
  • IHCAP application form

Renewal and Re-Authorization

Annual Renewal Requirements

Most Cometriq approvals require annual renewal. Start the process 60-90 days before your current authorization expires.

Renewal Documentation:

  • Updated treatment response assessment
  • Continued medical necessity justification
  • Current imaging and lab results
  • Any new safety considerations

Plan Year Changes

Monitor formulary changes during annual enrollment periods (typically October-January). If Cometriq moves to a higher tier or becomes non-formulary, you may have appeal rights.

Cost Assistance and Financial Support

Manufacturer Support

Exelixis Access Services (EASE):

  • Prior authorization assistance
  • Appeals support
  • Financial assistance programs
  • Contact: cometriq.com/support

Copay Assistance

Eligible commercially insured patients may qualify for manufacturer copay cards to reduce out-of-pocket costs.

Foundation Grants

Patient advocacy organizations and pharmaceutical foundations offer grants for cancer medications. Research options specific to thyroid cancer.

Quick Reference Checklist

Before Submitting:

  • Pathology confirms medullary thyroid carcinoma
  • Prescription specifies Cometriq capsules
  • Complete treatment history documented
  • Specialty pharmacy identified
  • PA form completed fully

If Denied:

  • File Level 1 appeal within 180 days
  • Include additional clinical justification
  • Request peer-to-peer review if available
  • Prepare for Level 2 appeal if needed
  • Know IHCAP deadline (180 days from final denial)

Frequently Asked Questions

Q: How long does Cigna prior authorization take in New Jersey? A: New Jersey law requires Cigna to respond within 72 hours for standard requests and 24 hours for urgent requests. Failure to meet these deadlines may result in automatic approval.

Q: What if Cometriq is not on my Cigna formulary? A: You can request a formulary exception with documented medical necessity. Your oncologist must demonstrate why covered alternatives are inappropriate.

Q: Can I request an expedited appeal if my condition is worsening? A: Yes. Urgent appeals must be processed within 72 hours. Provide documentation of immediate medical need.

Q: What's the difference between Cometriq and Cabometyx? A: Cometriq capsules are FDA-approved for metastatic MTC; Cabometyx tablets are not. Insurance will deny coverage if the wrong formulation is prescribed.

Q: How much will I pay out-of-pocket? A: Specialty tier medications typically have 25-50% coinsurance. Exact costs depend on your specific plan and out-of-pocket maximum.

Q: What if I've already started treatment and then get denied? A: Continue your appeal process. New Jersey allows appeals for reimbursement of services already provided if they're later deemed medically necessary.

When Coverage Gets Complex: Expert Help

Navigating prior authorization for specialty oncology drugs like Cometriq can be overwhelming, especially when facing denials or complex appeal processes. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

From Our Advocates: "We've seen many Cometriq denials overturned simply by correcting the formulation error—ensuring the prescription specifically requests capsules rather than tablets—and providing clear documentation of metastatic MTC diagnosis. The key is matching the clinical picture exactly to FDA labeling and payer criteria."

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance representative. Coverage policies and procedures may vary by plan and change over time. Always verify current requirements with your specific insurance plan and consult with qualified healthcare professionals regarding your treatment decisions.

For additional support with complex coverage issues, consider consulting with patient advocacy organizations or services like Counterforce Health that specialize in insurance appeals for specialty medications.

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