By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (cabozantinib) Covered by Cigna in Texas: Complete Cost-Saving and Appeals Guide

Answer Box: Cometriq (cabozantinib capsules) requires prior authorization from Cigna in Texas, typically approved for medullary thyroid carcinoma patients ≥18 years old through their specialty pharmacy network (Accredo). Start by having your oncologist submit a PA request via Cigna's provider portal with your MTC diagnosis (ICD-10 C73), progressive disease documentation, and medical necessity letter. If denied, you have 180 days to file an internal appeal, followed by external review through Texas's Independent Review Organization. Commercial insurance patients can access Exelixis copay assistance to reduce out-of-pocket costs to $0/month.

Table of Contents

What Drives Cometriq Costs with Cigna

Understanding your Cigna plan's benefit design helps you navigate the approval process and minimize out-of-pocket expenses for Cometriq (cabozantinib capsules).

Specialty Drug Classification

Cometriq is classified as a specialty medication by Cigna, typically placed on Tier 4 or 5 of their formulary with 20-50% coinsurance rather than flat copays. This high-cost oral cancer therapy for metastatic medullary thyroid carcinoma carries a cash price of approximately $18,938 for a 112-capsule pack (28-day supply at 140 mg daily).

Prior Authorization Requirements

All Cigna plans require prior authorization for Cometriq, with specific criteria including:

  • Patient age ≥18 years
  • Diagnosis of metastatic medullary thyroid carcinoma (ICD-10 C73)
  • Oncologist prescription
  • Documentation of progressive disease
  • No contraindications (severe bleeding, GI perforation)
Note: Cometriq capsules are not interchangeable with Cabometyx tablets. Ensure your prescription specifies the correct formulation to avoid automatic denials.

Investigating Your Cigna Benefits

Before starting treatment, gather key information about your specific plan's coverage.

Coverage Information to Collect

From Your Cigna Member Portal or ID Card:

  • Plan name and member ID
  • Pharmacy benefit manager (typically Express Scripts)
  • Specialty tier coinsurance percentage
  • Annual deductible and out-of-pocket maximum
  • Whether you have medical or pharmacy benefit coverage for oral oncology drugs

Questions to Ask Cigna Member Services (1-800-244-6224):

  1. "Is Cometriq covered under my pharmacy or medical benefit?"
  2. "What's my coinsurance for specialty tier medications?"
  3. "Do I need to use Accredo specialty pharmacy?"
  4. "Has my annual deductible been met?"

Formulary Status Check

Cometriq may be:

  • Formulary (Tier 4/5): Covered with high coinsurance
  • Non-formulary: Requires formulary exception request
  • Step therapy: May require trying vandetanib first (less common)

Patient Assistance and Copay Programs

Multiple programs can significantly reduce your Cometriq costs if you have commercial insurance.

Exelixis Access Services (EASE) Co-Pay Program

Eligibility: Commercially insured patients (excludes Medicare, Medicaid, and other government programs) Benefit: Reduces copays to as little as $0 per month Enrollment: Self-enroll at www.activatethecard.com/exelixis or call 1-844-900-3273

Important: No income limits apply to the copay program, but it cannot be combined with government insurance.

EASE Patient Assistance Program (Free Drug)

For uninsured or underinsured patients:

  • Income limit: Up to 500% of Federal Poverty Level
  • Coverage: Free Cometriq for eligible patients with medullary thyroid cancer
  • Application: Fax completed form to 1-844-901-3273

Third-Party Assistance in Texas

Under Texas Insurance Code §1369.0542, Cigna must apply manufacturer copay assistance, foundation grants, and other third-party payments toward your deductible and out-of-pocket maximum when the drug is covered.

Formulary Exception Requests

If Cometriq is non-formulary or placed on a high-cost tier, you can request an exception.

When to Request an Exception

  • Cometriq is not on your plan's formulary
  • You want to move from Tier 5 to a lower tier
  • Step therapy requires trying vandetanib first, but it's contraindicated

Documentation Requirements

Your oncologist must provide written certification including:

  • Evidence that formulary alternatives failed, caused adverse effects, or are contraindicated
  • Clinical rationale why Cometriq provides superior therapeutic outcomes
  • Supporting literature (NCCN guidelines, FDA labeling, peer-reviewed studies)

Review Timeline

  • Standard: Within 72 hours
  • Expedited: Within 24 hours for life-threatening conditions
Clinician Corner: Include specific details about MTC progression, prior therapy failures, and why alternatives like vandetanib are inappropriate. Reference NCCN Thyroid Carcinoma guidelines and FDA-approved indications.

Specialty Pharmacy Requirements

Cigna typically requires Cometriq to be dispensed through their specialty pharmacy network.

Accredo Specialty Pharmacy

Most Cigna plans use Accredo for specialty drug dispensing:

  • Retail limit: 28-day supply (1 carton)
  • Mail order: Up to 84-day supply (3 cartons)
  • No refrigeration required
  • Coordination: Accredo handles prior authorization and insurance billing

Quantity Limits

Standard dosing allowances per prescription:

  • 140 mg daily: 112 capsules retail, 336 capsules mail order
  • 100 mg daily: 112 capsules retail, 336 capsules mail order
  • With CYP3A4 inducers: Higher quantities may be approved

Appeals Process in Texas

Texas law provides strong patient rights for appealing Cigna denials, especially for specialty drugs.

Internal Appeal Process

Timeline: 180 days from denial to file appeal Decision timeframe:

  • Standard: 30 days for pre-service requests
  • Expedited: 72 hours for urgent cases

Required documentation:

  • Original denial letter
  • Medical necessity letter from oncologist
  • Chart notes showing MTC diagnosis and progression
  • Evidence of prior treatment failures
  • Supporting literature (NCCN guidelines, FDA labeling)

External Review Rights

If your internal appeal is denied, Texas law provides access to Independent Review Organization (IRO) review:

  • Timeline: 4 months from final internal denial
  • Cost: Free to patients
  • Decision timeframe: 20 days standard, 5 days expedited
  • Binding: IRO decisions are enforceable against Cigna

When to Request Expedited Review

Request expedited appeals when:

  • MTC is progressing rapidly
  • Delay would jeopardize health or treatment effectiveness
  • You're currently on treatment and facing interruption
From our advocates: In our experience with Texas specialty drug appeals, patients who submit comprehensive medical documentation—including imaging showing disease progression and detailed prior therapy records—see higher overturn rates. The key is demonstrating that Cometriq is not just preferred, but medically necessary for your specific situation.

Annual Renewal Planning

Cigna formularies and coverage policies can change annually, affecting your Cometriq access and costs.

What Changes Each Year

  • Formulary tier placement
  • Prior authorization criteria
  • Specialty pharmacy networks
  • Coinsurance percentages

Renewal Checklist

  1. Review new formulary (available October for following year)
  2. Confirm Cometriq remains covered
  3. Check for new step therapy requirements
  4. Verify Accredo remains in-network
  5. Renew copay assistance programs

Communication Scripts

Calling Cigna Member Services

"Hi, I'm calling to verify coverage for Cometriq, spelled C-O-M-E-T-R-I-Q, the capsule formulation for my medullary thyroid cancer. I need to know my prior authorization status, specialty tier coinsurance, and whether I must use Accredo pharmacy."

Provider Peer-to-Peer Request

"I'm requesting a peer-to-peer review for my patient's Cometriq denial. They have progressive metastatic medullary thyroid carcinoma, and vandetanib is contraindicated due to [specific reason]. Can we schedule a call with your oncology medical director?"

Pharmacy Coordination

"I have Cigna insurance and need to fill Cometriq capsules through Accredo. My doctor submitted the prior authorization yesterday. Can you check the status and coordinate with my insurance?"

FAQ

How long does Cigna prior authorization take for Cometriq? Standard PA decisions are typically made within 15 business days, though automated approvals meeting clear criteria may process within 24-72 hours. Expedited requests are decided within 72 hours.

What if Cometriq is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification from your oncologist. If denied, appeal through internal review, then external review via Texas IRO.

Can I use retail pharmacy instead of Accredo? Most Cigna plans require specialty drugs like Cometriq to be dispensed through Accredo. Retail pharmacies typically cannot fill these prescriptions even with prior authorization.

Does step therapy apply if I tried vandetanib outside Texas? Yes, prior therapy records from any state count toward step therapy requirements. Provide documentation of vandetanib trial and failure/intolerance.

How do I get help with appeals in Texas? Contact the Texas Department of Insurance at 1-800-252-3439 or the Office of Public Insurance Counsel at 1-877-611-6742 for assistance with insurance appeals.

What happens if I lose Cigna coverage mid-treatment? Contact EASE immediately at 1-844-900-3273 to explore bridge programs or patient assistance. Don't stop treatment without consulting your oncologist.

About Counterforce Health: Counterforce Health helps patients and clinicians navigate complex prior authorization and appeals processes by analyzing denial letters, identifying specific coverage criteria, and drafting evidence-based appeals that address payer requirements point-by-point. Our platform streamlines the approval process for specialty drugs like Cometriq, reducing administrative burden while improving patient access to critical treatments.

For patients facing Cigna denials in Texas, Counterforce Health's automated system can quickly identify the specific basis for denial—whether it's step therapy requirements, formulary status, or medical necessity criteria—and generate targeted appeals that align with both Cigna's internal policies and Texas insurance law requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan. Always consult with your healthcare provider and insurance company for specific coverage determinations. For personalized assistance with appeals, contact qualified patient advocates or legal professionals.

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