By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Cigna in North Carolina: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Cometriq (Cabozantinib) Covered by Cigna in North Carolina

Cometriq (cabozantinib) requires prior authorization through Cigna and must be filled at Accredo specialty pharmacy for coverage. Your oncologist submits clinical documentation proving medical necessity for metastatic medullary thyroid carcinoma. If denied, you have 180 days for internal appeals, then 120 days for North Carolina's Smart NC external review (80% success rate for well-documented cases). First step today: Have your doctor call Cigna at the number on your ID card to start the PA process while gathering your MTC diagnosis records and prior treatment history.

Table of Contents

What Drives Cometriq Coverage Costs

Cometriq (cabozantinib capsules) carries a cash price around $18,938 for a 112-capsule pack (typical monthly supply), making it one of the most expensive oral cancer therapies. Your out-of-pocket costs depend on several benefit design factors:

Formulary Tier Placement: Most Cigna plans place Cometriq on Tier 4 (specialty) or Tier 5 (non-preferred specialty), meaning higher coinsurance rates—often 25-40% after deductible.

Prior Authorization Requirements: Coverage requires your oncologist to prove medical necessity through clinical documentation, adding processing time but ensuring appropriate use.

Specialty Pharmacy Mandate: Cigna typically requires Cometriq to be dispensed through Accredo specialty pharmacy rather than retail locations, affecting convenience and potentially costs.

Note: Unlike Cabometyx tablets, Cometriq capsules are specifically FDA-approved for medullary thyroid carcinoma and are not interchangeable formulations.

Investigating Your Cigna Benefits

Before your oncologist submits the prior authorization, gather this information to understand your coverage:

Call the number on your Cigna ID card and ask:

  • Is Cometriq (cabozantinib capsules) on my plan's formulary?
  • What tier is it placed on, and what's my coinsurance rate?
  • Does my plan require step therapy before covering Cometriq?
  • Must I use Accredo specialty pharmacy for coverage?
  • What's my specialty drug deductible and annual out-of-pocket maximum?

Log into your myCigna account to:

  • View your current drug list and coverage details
  • Check prior authorization status once submitted
  • Review your annual drug spending toward out-of-pocket limits

Record this information:

  • Plan name and member ID
  • Formulary tier and coinsurance percentage
  • Specialty pharmacy requirements
  • Any step therapy protocols mentioned

Step-by-Step: Fastest Path to Approval

1. Oncologist Initiates Prior Authorization

Who: Your prescribing oncologist or their staff
What: Submit PA request with clinical documentation
How: Call Cigna or use myCigna provider portal
Timeline: 72 hours for standard review, 24 hours if expedited
Source: Cigna formulary exception process

2. Gather Required Clinical Evidence

Who: Patient and oncology team
What: Medical records proving MTC diagnosis and treatment need
Documents needed:

  • Pathology report confirming medullary thyroid carcinoma
  • ICD-10 diagnosis codes (C73 for thyroid cancer)
  • Imaging showing metastatic disease
  • Documentation of prior therapies tried/failed (if applicable)
  • Current performance status and treatment goals

3. Submit to Accredo if Approved

Who: Patient or prescriber
What: Transfer prescription to Cigna's preferred specialty pharmacy
How: Call Accredo at number provided in approval letter
Timeline: 1-3 business days for first fill

4. Monitor for Denial and Prepare Appeal

Who: Patient and oncology team
What: Review any denial reasons and gather additional evidence
Timeline: Response within 72 hours; appeal window opens immediately

Financial Assistance Options

Even with Cigna coverage, your specialty tier coinsurance can result in monthly costs of $2,000-$5,000. Here are ways to reduce expenses:

Manufacturer Copay Support

Exelixis Access Services (EASE) offers copay assistance for commercially insured patients. Eligible patients can pay as little as $0 per month through the copay card program.

  • Eligibility: Commercial insurance required (not Medicare, Medicaid, or other government plans)
  • Apply: activatethecard.com/exelixis or through your oncology team
  • Limitations: Annual caps apply; verify current terms when enrolling

Independent Foundation Grants

Good Days Foundation specifically covers medullary thyroid cancer patients with insurance:

  • Assists with copays when insurance pays at least 50% of treatment cost
  • Apply at mygooddays.org
  • Funding opens/closes unpredictably; check monthly if currently closed

Additional Support Organizations

  • CancerCare: Provides financial navigation and limited emergency grants at (800) 813-4673
  • ThyCa (Thyroid Cancer Survivors' Association): Offers support resources at thyca.org
  • Patient Advocate Foundation: Financial aid fund applications at patientadvocate.org
From our advocates: We've seen MTC patients successfully combine manufacturer copay cards with foundation grants to reduce monthly costs from $3,200 to under $50. The key is applying to multiple programs simultaneously since funding availability changes frequently.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Wrong formulation (Cabometyx vs. Cometriq) Clarify capsule-specific approval for MTC FDA labeling showing Cometriq capsules for MTC indication
Insufficient diagnosis documentation Submit complete pathology and imaging Pathology report, CT/MRI showing metastases, ICD-10 codes
Missing prior therapy trials Document treatment history or contraindications Chart notes showing vandetanib trial/failure or medical contraindication
"Not medically necessary" Provide clinical guidelines and treatment rationale NCCN guidelines, oncologist letter explaining treatment goals

Appeals are often successful when clinical evidence is comprehensive. Cigna's Medicare Advantage members appeal PA denials at ~18% rates, suggesting many initial denials are overturned with proper documentation.

Appeals Playbook for Cigna in North Carolina

Internal Appeals (Required First Step)

Level 1 Internal Appeal:

  • Deadline: 180 days from denial date
  • How to file: Call Cigna customer service or submit written appeal
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required: Copy of denial letter, additional clinical evidence, prescriber statement

Level 2 Internal Appeal:

  • When: If Level 1 is denied
  • Timeline: 30 days for review
  • Process: Independent medical review by Cigna

North Carolina External Review

After exhausting Cigna's internal appeals, North Carolina residents can request external review through Smart NC:

Eligibility:

  • Completed all internal Cigna appeals
  • State-regulated plan (verify with Smart NC if unsure)
  • Denial based on medical necessity or experimental treatment determination

How to Apply:

  • Deadline: 120 days from final Cigna denial
  • Submit: Smart NC External Review Request Form
  • Contact: 855-408-1212 for free assistance with your application
  • Timeline: 45 days for standard review, 72 hours for expedited

Success Rates: Well-documented specialty drug appeals through Smart NC achieve success rates up to 80%, particularly for cancer medications with strong clinical evidence.

If External Review Approves Coverage: Cigna must provide coverage within 3 business days of the decision.

Specialty Pharmacy Requirements

Cigna typically mandates that Cometriq be dispensed through Accredo specialty pharmacy for coverage. This requirement affects your access and costs:

Benefits of Accredo:

  • Integrated with Cigna's prior authorization system
  • Clinical pharmacists specializing in oncology medications
  • Home delivery with temperature-controlled shipping
  • Patient support services and adherence monitoring

Coordination Tips:

  • Ensure your oncologist sends prescriptions directly to Accredo
  • Verify your shipping address and preferred delivery schedule
  • Confirm Accredo has your current insurance information
  • Ask about 90-day supplies to reduce shipping frequency

Alternative Options:

  • Some Cigna plans allow retail specialty pharmacies with higher copays
  • Verify network requirements specific to your plan before filling elsewhere

When Treatment is Urgent

If you need Cometriq immediately due to rapidly progressing medullary thyroid carcinoma, expedited pathways are available:

Expedited Prior Authorization:

  • Request 24-hour review when submitting initial PA
  • Include physician statement about urgent medical need
  • Provide clinical evidence of disease progression

Expedited Appeals:

  • Available for both internal Cigna appeals and Smart NC external review
  • Timeline: 72 hours for internal, 72 hours for Smart NC external review
  • Criteria: Delay would seriously jeopardize life, health, or ability to regain function

Bridge Therapy:

  • Ask oncologist about temporary alternatives while appeals process
  • Some patients receive samples or foundation emergency grants
  • Counterforce Health can help expedite evidence-backed appeals with proper clinical documentation

FAQ: North Carolina Cometriq Coverage

How long does Cigna prior authorization take for Cometriq in North Carolina?
Standard PA review takes 72 hours; expedited review for urgent cases takes 24 hours. Your oncologist receives notification once processed.

What if Cometriq is non-formulary on my Cigna plan?
Request a formulary exception through your prescriber. Include clinical evidence showing medical necessity and any contraindications to formulary alternatives like vandetanib.

Can I request an expedited appeal if Cigna denies Cometriq?
Yes, both Cigna internal appeals and Smart NC external review offer expedited pathways (72 hours each) if delay would jeopardize your health.

Does step therapy apply if I've tried treatments outside North Carolina?
Yes, document prior therapy trials from any location. Include medical records, treatment dates, and reasons for discontinuation (inefficacy, intolerance, progression).

What happens if Smart NC external review denies my appeal?
The external review decision is binding on Cigna. You may have other legal rights, but the administrative appeals process is exhausted.

How do I prove medical necessity for metastatic medullary thyroid carcinoma?
Submit pathology confirming MTC diagnosis, imaging showing metastatic disease, documentation of disease progression, and oncologist letter explaining treatment rationale aligned with NCCN guidelines.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals. For complex cases involving specialty oncology medications like Cometriq, their platform helps clinicians gather the right clinical evidence and regulatory citations to strengthen prior authorization requests and appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for decisions about your treatment and coverage. Insurance policies and requirements may vary; verify current information with official sources before making coverage decisions.

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