By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Cigna in Pennsylvania: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Cometriq Covered by Cigna in Pennsylvania

Cigna covers Cometriq (cabozantinib capsules) for metastatic medullary thyroid carcinoma with prior authorization. Your oncologist submits a PA request including pathology confirming MTC diagnosis, recent imaging showing progression, and elevated calcitonin/CEA levels. If denied, Pennsylvania's new Independent External Review program has overturned about 50% of appealed denials in 2024. First step today: Have your doctor call Cigna at 1-800-882-4462 to initiate the PA process while you verify your benefits through myCigna.com.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Medical Necessity Criteria
  5. Costs and Financial Assistance
  6. Denials and Appeals in Pennsylvania
  7. Renewal Requirements
  8. Specialty Pharmacy Requirements
  9. Common Issues and Solutions
  10. FAQ

Coverage Basics

Is Cometriq Covered by Cigna?

Yes, Cigna covers Cometriq (cabozantinib capsules) as a specialty medication for FDA-approved indications. The drug appears on Cigna formularies as Tier 4 or 5 (specialty tier) with prior authorization requirements and typically requires dispensing through Accredo specialty pharmacy.

Important: Cometriq capsules are not interchangeable with Cabometyx tablets. These are distinct formulations with different coverage criteria.

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all plans Cigna Provider Portal
Formulary Tier Tier 4-5 (20-50% coinsurance) myCigna member portal
Step Therapy None for MTC indication Cigna PA Policy CNF504
Age Requirement ≥18 years old FDA labeling
Specialty Pharmacy Accredo required Cigna member services

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Doctor gathers documentation (1-2 days)
    • Pathology report confirming medullary thyroid carcinoma
    • Recent imaging (CT/MRI within 3 months) showing metastases/progression
    • Lab results: elevated calcitonin and/or CEA levels
    • Treatment history and prior therapy failures
  2. Submit PA request (same day)
    • Online via Cigna Provider Portal or CoverMyMeds
    • Phone: 1-800-882-4462
    • Include ICD-10 code C73 with metastatic modifiers
  3. Cigna reviews submission (72 hours standard, 24 hours expedited)
    • Automated approval possible if all criteria met
    • May request additional documentation
  4. If approved, Accredo contacts patient (1-2 business days)
    • Enrollment in specialty pharmacy program
    • Copay assistance screening
    • Home delivery coordination

Required Documentation Checklist

  • Pathology report explicitly stating "medullary thyroid carcinoma"
  • Imaging reports with progression dates and measurements
  • Calcitonin and/or CEA lab values (elevated levels)
  • Prior systemic therapy records (if applicable)
  • Medical necessity letter from oncologist
  • Patient age verification (≥18 years)
  • Performance status assessment
  • Contraindication screening results

Timing and Urgency

Standard Timeline

  • PA submission to decision: 72 hours (3 business days)
  • Approval to first shipment: 2-3 business days via Accredo
  • Total time to medication: 5-6 business days

Expedited Process

For urgent cases where delay could seriously jeopardize health:

  • Decision timeline: 24 hours
  • How to request: Doctor specifies "urgent/expedited" on PA form
  • Documentation needed: Clinical rationale for urgency
Tip: If your oncologist indicates disease progression is rapid or you're experiencing severe symptoms, request expedited review to accelerate the timeline.

Medical Necessity Criteria

Cigna approves Cometriq when all of the following criteria are met:

Primary Requirements

  1. Confirmed diagnosis: Pathology-proven metastatic medullary thyroid carcinoma
  2. Age requirement: Patient must be 18 years or older
  3. Disease status: Progressive or metastatic disease documented by imaging
  4. Biomarkers: Elevated calcitonin and/or carcinoembryonic antigen (CEA)
  5. Prescriber: Oncologist or endocrinologist with thyroid cancer expertise

Exclusion Criteria

Cometriq will be denied if patient has:

  • Severe bleeding disorders or active bleeding
  • GI perforation risk
  • Uncontrolled hypertension
  • Severe hepatic impairment
  • Pregnancy or nursing

Clinician Corner: Medical Necessity Letter

Your oncologist's letter should include:

  • Problem statement: Progressive metastatic MTC despite [prior treatments]
  • Clinical rationale: FDA-approved indication, NCCN guidelines support
  • Monitoring plan: Regular labs, imaging, toxicity assessments
  • Treatment goals: Disease stabilization, symptom control, survival benefit
  • Contraindication review: No bleeding/perforation risks identified

Costs and Financial Assistance

Typical Out-of-Pocket Costs

  • Tier 4 coinsurance: 25-33% after deductible
  • Tier 5 coinsurance: 40-50% after deductible
  • Monthly cost: $3,000-$9,000 before assistance (verify plan-specific amounts)

Exelixis EASE Copay Program

  • Benefit: $0/month for eligible patients
  • Eligibility: Commercial insurance (not Medicare/Medicaid)
  • Enrollment: cometriq.com/support or 1-844-900-3273
  • Activation: Link card to Accredo account

Additional Assistance Options

  • PAN Foundation: Income-based grants for cancer patients
  • CancerCare: Copay assistance and support services
  • Exelixis Patient Assistance Program: Free drug for uninsured (up to 500% FPL)

Counterforce Health helps patients navigate insurance denials and identify all available assistance programs through their platform that analyzes denial letters and connects patients with appropriate resources.

Denials and Appeals in Pennsylvania

Common Denial Reasons and Solutions

Denial Reason How to Fix Documentation Needed
"Not medically necessary" Submit progression evidence Recent scans, biomarker trends
"Experimental/investigational" Cite FDA approval for MTC FDA label, prescribing information
Wrong formulation Specify capsules vs. tablets Prescription clarification
Missing pathology Provide MTC confirmation Pathology report with diagnosis

Pennsylvania's External Review Process

Pennsylvania launched its Independent External Review program in January 2024, offering patients a powerful tool to overturn insurance denials.

Key Statistics: In the program's first year, about 50% of appealed denials were overturned, with over 100 successful appeals resulting in coverage for initially denied treatments.

Appeals Timeline

  1. Internal Appeal (Level 1)
    • Deadline: 180 days from denial letter
    • Decision time: 30 days (15 days for urgent)
    • Submit to: Cigna Appeals Department
  2. Internal Appeal (Level 2)
    • Deadline: 60 days from Level 1 denial
    • Decision time: 30 days
    • Required: Final Adverse Benefit Determination letter
  3. Pennsylvania External Review
    • Deadline: 4 months from Final Adverse Benefit Determination
    • Decision time: 45 days (72 hours for urgent)
    • Submit via: pa.gov/reviewmyclaim
    • Success rate: ~53% of denials overturned
From our advocates: We've seen patients successfully overturn Cigna denials for specialty cancer drugs by submitting comprehensive medical records and NCCN guideline citations through Pennsylvania's external review process. The key is thorough documentation of medical necessity and disease progression.

How to File External Review in Pennsylvania

  1. Complete internal appeals first - obtain Final Adverse Benefit Determination letter
  2. Visit pa.gov/reviewmyclaim within 4 months
  3. Submit request explaining why coverage should be approved
  4. Include supporting documents: medical records, physician letters, treatment guidelines
  5. Independent Review Organization (IRO) reviews case - certified physicians make binding decision
  6. If approved, Cigna must provide coverage immediately

For assistance with the external review process, contact Pennsylvania Insurance Department consumer services at 1-877-881-6388.

Renewal Requirements

Annual Reauthorization

  • When: 12 months from initial approval
  • Process: Doctor submits updated clinical information
  • Required updates: Recent imaging, biomarker levels, treatment response, toxicity assessment

What Triggers Early Reauthorization

  • Dose changes beyond approved range
  • Treatment interruptions >30 days
  • New contraindications or safety concerns
  • Insurance plan changes

Specialty Pharmacy Requirements

Why Accredo is Required

Cigna mandates specialty pharmacy dispensing for Cometriq to ensure:

  • Clinical monitoring and safety oversight
  • Copay assistance coordination
  • Adherence support and side effect management
  • Temperature-controlled shipping and storage

Accredo Enrollment Process

  1. Automatic transfer after PA approval
  2. Patient intake call within 24-48 hours
  3. Insurance verification and copay assistance screening
  4. First shipment typically within 2-3 business days
  5. Ongoing support including refill reminders and clinical check-ins

Contact Accredo directly at 1-800-803-2523 for enrollment questions.

Common Issues and Solutions

Portal and Technical Problems

  • Cigna provider portal down: Use fax backup or call 1-800-882-4462
  • Missing PA forms: Download from Cigna Provider Resources
  • Accredo enrollment delays: Call patient services at 1-800-803-2523

Documentation Issues

  • Pathology report doesn't specify MTC: Request addendum from pathologist
  • Imaging reports lack progression details: Ask radiologist for supplemental interpretation
  • Missing biomarker values: Order calcitonin and CEA if not done recently

Coverage Verification Problems

  • Can't access myCigna: Call member services number on insurance card
  • Formulary status unclear: Verify current PDL with Cigna directly
  • Specialty pharmacy requirement disputed: Reference Cigna policy requiring Accredo for Cometriq

When facing persistent issues, Counterforce Health can help analyze denial letters and develop targeted appeal strategies based on your specific plan's coverage policies.

FAQ

How long does Cigna prior authorization take for Cometriq in Pennsylvania? Standard PA decisions are made within 72 hours (3 business days). Expedited reviews for urgent cases are completed within 24 hours.

What if Cometriq is non-formulary on my Cigna plan? Cometriq appears on most Cigna formularies as a covered specialty drug. If it's truly non-formulary, your doctor can request a formulary exception with medical necessity justification.

Can I request an expedited appeal in Pennsylvania? Yes, both Cigna's internal appeals and Pennsylvania's external review process offer expedited timelines when delay could seriously jeopardize your health or ability to regain maximum function.

Does step therapy apply if I haven't tried other treatments? No, Cigna's policy for Cometriq in medullary thyroid carcinoma does not require step therapy or prior trial of other medications.

What's the difference between Cometriq and Cabometyx coverage? Cometriq (capsules) is covered specifically for medullary thyroid carcinoma, while Cabometyx (tablets) is covered for renal cell carcinoma and hepatocellular carcinoma. They are not interchangeable formulations.

How do I check if my Cigna plan requires Accredo? Log into myCigna.com or call the member services number on your insurance card. Most Cigna plans require specialty drugs like Cometriq to be dispensed through Accredo.

What happens if I'm denied and don't appeal? You'll be responsible for the full cash price (approximately $18,938 for a 28-day supply). Pennsylvania's external review process offers a strong chance of overturning the denial - about 50% success rate in 2024.

Can I get help with the appeals process? Yes, Pennsylvania offers free consumer assistance through the Pennsylvania Health Law Project, and the Insurance Department's consumer services line (1-877-881-6388) can guide you through the external review process.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies vary by plan and may change. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals and coverage issues, consider consulting with patient advocacy services or legal professionals specializing in healthcare coverage.

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