By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Cigna in New York: Prior Authorization, Appeals & Cost Assistance

Answer Box: Getting Cometriq (Cabozantinib) Covered by Cigna in New York

Cometriq requires prior authorization from Cigna and must be dispensed through specialty pharmacy. The fastest path: 1) Have your oncologist submit a complete PA request with diagnosis, treatment history, and clinical rationale within 72 hours, 2) If denied, file internal appeal immediately, then 3) Use New York's external appeal process through DFS within 4 months. Start by confirming your plan's formulary status and gathering medical records showing medullary thyroid cancer diagnosis and any prior treatment failures.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must get approval before prescribing Cigna PA forms Cigna Policy
Specialty Tier Placement Higher cost-sharing (25-50% coinsurance typical) Your plan's formulary Plan Documents
Specialty Pharmacy Only Must fill at approved specialty pharmacy Express Scripts/Accredo network Cigna Specialty
Quantity Limits Usually 30-day supply maximum Formulary documents Plan Policy
Diagnosis Requirement Medullary thyroid carcinoma (C73.9) Coverage criteria Cigna Medical Policy

Step-by-Step: Fastest Path to Approval

1. Verify Formulary Status

Who: Patient or clinic staff
Action: Check if Cometriq is covered on your specific Cigna plan
Timeline: 15 minutes
Submit via: Cigna formulary lookup

2. Gather Required Documentation

Who: Your oncologist's office
Documents needed:

  • Medullary thyroid carcinoma diagnosis with ICD-10 code
  • Pathology reports confirming MTC
  • Previous treatment history and outcomes
  • Current staging and progression notes Timeline: 1-2 business days

3. Submit Prior Authorization Request

Who: Prescribing physician
Action: Complete PA form with clinical justification
Timeline: Cigna responds within 72 hours (24 hours if urgent)
Submit via: Cigna provider portal or fax (verify current number with plan)

4. Coordinate Specialty Pharmacy

Who: Patient with clinic support
Action: Set up delivery through approved specialty pharmacy
Timeline: 2-3 business days after approval
Contact: Express Scripts specialty pharmacy network

5. If Denied: File Internal Appeal

Who: Patient or authorized representative
Action: Submit appeal with additional clinical documentation
Timeline: Must file within plan's appeal deadline (typically 180 days)
Submit via: Written appeal to Cigna appeals department

6. External Appeal (If Needed)

Who: Patient
Action: File with New York State Department of Financial Services
Timeline: Within 4 months of final denial
Submit to: NY DFS External Appeal

What Drives Your Out-of-Pocket Costs

Cometriq's annual cost exceeds $279,000 before insurance, making it a high-cost specialty medication that Cigna places on their highest formulary tiers. Your out-of-pocket expenses depend on several benefit design factors:

Specialty Tier Placement: Most Cigna plans place Cometriq on Tier 4 or 5 (specialty tiers), typically requiring 25-50% coinsurance rather than fixed copays. This means you pay a percentage of the drug's cost until reaching your plan's out-of-pocket maximum.

Deductible Impact: If your plan has a separate specialty drug deductible, you'll pay the full cost until meeting that threshold. Some plans have combined medical/pharmacy deductibles.

Out-of-Pocket Maximum: Once you reach your annual out-of-pocket limit (often $3,000-$8,000 for individual coverage), the plan covers 100% of remaining costs.

Tip: Ask your benefits administrator about specialty drug cost-sharing caps. Some states have laws limiting monthly out-of-pocket costs for oral cancer medications.

Investigating Your Benefits

Before starting treatment, gather this information by calling the member services number on your insurance card:

Questions to Ask Cigna:

  • "Is Cometriq on my plan's formulary and what tier?"
  • "What's my specialty drug coinsurance percentage?"
  • "Do I have a separate specialty drug deductible?"
  • "Which specialty pharmacies are in-network?"
  • "What's my annual out-of-pocket maximum?"

Information to Record:

  • Your specific plan name and policy number
  • Prior authorization requirements and forms needed
  • Appeal deadlines and procedures
  • Specialty pharmacy contact information
  • Any step therapy requirements

Financial Assistance Options

Manufacturer Copay Program

Exelixis offers a copay card that reduces monthly costs to $0 for eligible patients with commercial insurance. Key restrictions:

  • Must have commercial/private insurance (not Medicare, Medicaid, or other government programs)
  • No explicit income limits for the copay card
  • Annual and transaction limits apply

How to Apply: Visit Exelixis Access Services or call their patient support line.

Patient Assistance Program

For uninsured or underinsured patients, Exelixis provides a separate assistance program that may involve income verification and documentation of financial need.

Foundation Grants

Several cancer foundations offer grants for medication costs:

  • Patient Access Network Foundation
  • Good Days Foundation
  • CancerCare Co-Payment Assistance Foundation

State Programs

New York residents may qualify for additional assistance through state pharmaceutical programs, particularly if enrolled in Medicaid or the Essential Plan.

When to Request Tiering Exceptions

If Cometriq is placed on a high specialty tier, you can request a formulary exception to move it to a lower tier with reduced cost-sharing. This process requires:

Clinical Documentation:

  • Letter from your oncologist explaining why lower-tier alternatives are inappropriate
  • Evidence of treatment failure or intolerance to preferred drugs
  • Literature supporting Cometriq's effectiveness for your specific condition

Timeline: Cigna must respond within 72 hours for standard requests, 24 hours for urgent cases.

Success Factors:

  • Clear documentation of medical necessity
  • Evidence that formulary alternatives have failed or are contraindicated
  • Support from current treatment guidelines (NCCN, FDA labeling)

Specialty Pharmacy Requirements

Cigna requires Cometriq to be dispensed through their specialty pharmacy network, typically Express Scripts or Accredo. This requirement exists because:

Clinical Support: Specialty pharmacies provide enhanced patient education and monitoring for complex medications.

Cost Management: Insurers negotiate better pricing through specialty pharmacy contracts.

Safety Monitoring: Specialty pharmacies track side effects and drug interactions more closely.

Note: After a limited number of retail fills (usually 1-2), Cigna will require you to switch to specialty pharmacy or lose coverage.

Coordination Tips:

  • Set up specialty pharmacy account before your first fill
  • Ensure your oncologist's office has the correct specialty pharmacy contact information
  • Plan for shipping times (typically 1-2 business days)
  • Keep specialty pharmacy contact information handy for refill coordination

Appeals Process for New York Patients

New York provides robust appeal rights through a two-level process: internal appeals with Cigna, followed by external review through the state.

Internal Appeals

First Level: Submit written appeal within 180 days of denial Second Level: If first appeal is denied, request second-level review Timeline: Cigna has specific timeframes to respond (verify current requirements)

External Appeals Through NY DFS

New York's external appeal process is particularly strong for specialty drug denials:

Eligibility: Available after receiving final adverse determination from Cigna Timeline: Must file within 4 months of final denial Process: Independent medical experts review your case Cost: Maximum $25 fee (waived for financial hardship) Decision: Binding on Cigna if approved

Required Documentation:

Submit to:
New York State Department of Financial Services
99 Washington Avenue, Box 177
Albany, NY 12210
Fax: (800) 332-2729

Tip: Use the DFS External Appeal Database to research how similar cases were decided and what evidence was most persuasive.

Planning for Annual Renewals

Cometriq's coverage can change annually when Cigna updates their formulary. Plan ahead by:

October-November: Review your plan's upcoming formulary changes during open enrollment December: Confirm Cometriq remains covered and note any new requirements January: Ensure prior authorization is current for the new plan year

Potential Changes:

  • Tier placement (higher or lower cost-sharing)
  • New step therapy requirements
  • Different quantity limits
  • Changed specialty pharmacy network

At Counterforce Health, we help patients navigate these annual changes by tracking formulary updates and assisting with appeals when coverage becomes more restrictive.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Submit clinical evidence showing MTC diagnosis and treatment appropriateness Pathology reports, oncologist letter, NCCN guidelines
"Step therapy required" Request exception based on contraindications to preferred drugs Documentation of adverse reactions or clinical unsuitability
"Non-formulary" File formulary exception request Comparative effectiveness data, cost-benefit analysis
"Quantity limits exceeded" Provide clinical justification for higher dosing Dosing rationale, weight-based calculations, monitoring plan

Conversation Scripts

Calling Cigna Member Services

"I'm calling about prior authorization for Cometriq, generic name cabozantinib, for medullary thyroid cancer. Can you tell me if this medication requires PA on my plan and what documentation is needed? I also need to know which specialty pharmacies are in-network for this medication."

Provider Peer-to-Peer Request

"I'm requesting a peer-to-peer review for my patient's Cometriq denial. The patient has medullary thyroid carcinoma confirmed by pathology, and Cometriq is FDA-approved and NCCN-recommended for this indication. When can we schedule the clinical discussion?"

Specialty Pharmacy Setup

"I need to set up specialty pharmacy service for Cometriq. My insurance is Cigna, and I have the prior authorization approval. Can you coordinate with my oncologist's office for the prescription transfer and confirm my delivery address?"

FAQ

How long does Cigna prior authorization take for Cometriq in New York? Standard requests: 72 hours. Urgent requests: 24 hours. If Cigna doesn't respond within these timeframes, the request is considered approved.

What if Cometriq is non-formulary on my Cigna plan? You can request a formulary exception with clinical documentation showing medical necessity. If denied, appeal through Cigna's internal process, then file an external appeal with NY DFS.

Can I request an expedited appeal if I'm already on Cometriq? Yes, if continuing treatment is urgent for your health. Both Cigna and NY DFS offer expedited review processes for urgent medical needs.

Does step therapy apply if I started Cometriq in another state? Cigna should honor prior authorizations from other states, but you may need to provide documentation of your treatment history and current medical necessity.

How much will Cometriq cost me with Cigna coverage? Costs vary by plan, but expect specialty tier coinsurance of 25-50% until you reach your out-of-pocket maximum. The Exelixis copay card can reduce costs to $0 monthly for eligible commercial insurance patients.

What happens if Cigna removes Cometriq from their formulary next year? You have appeal rights and can request a formulary exception. New York law provides additional protections for patients already on therapy when formulary changes occur.

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Cometriq. Our platform analyzes denial letters, identifies the specific coverage criteria, and drafts evidence-backed appeals that address payers' exact requirements. We help patients, clinicians, and specialty pharmacies navigate the prior authorization process more efficiently, reducing delays in accessing critical cancer treatments. Visit www.counterforcehealth.org to learn how we can support your coverage journey.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific plan and consult with your healthcare provider about treatment decisions. For personalized assistance with New York insurance appeals, contact Community Health Advocates at 888-614-5400 or the NY Department of Financial Services consumer helpline.

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