By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Humana in Illinois: Prior Authorization, Appeals, and Coding Guide

Answer Box: Getting Cometriq (Cabozantinib) Covered by Humana in Illinois

Cometriq requires prior authorization from Humana for medullary thyroid carcinoma (MTC). The fastest path: Your oncologist submits clinical documentation with ICD-10 code C73, pathology confirming MTC, and prior treatment history to Humana's provider portal or fax 877-486-2621. If denied, you have 65 days to appeal internally, then can request external review through the Illinois Department of Insurance within 4 months. Illinois law guarantees independent physician review with decisions in 30 days.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Medullary Thyroid Carcinoma
  3. Product Coding: NDC Numbers and Billing
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Pitfalls to Avoid
  6. Verification Steps with Humana
  7. Quick Audit Checklist
  8. Appeals Playbook for Illinois
  9. Common Denial Reasons & Solutions
  10. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Cometriq (cabozantinib capsules) flows through Medicare Part D pharmacy benefits under Humana plans, not the medical benefit. This distinction matters for coding and billing:

Pharmacy Benefit Path:

  • Uses NDC (National Drug Code) numbers
  • Requires prior authorization through pharmacy channels
  • Billed with diagnosis codes (ICD-10) for medical necessity
  • No HCPCS J-code exists for Cometriq capsules

Key Difference from Cabometyx: Cometriq capsules for MTC are not interchangeable with Cabometyx tablets used for other cancers. Each has distinct NDC codes and indications, and mixing them up is a common denial trigger.

Note: Unlike injectable cancer drugs, oral Cometriq doesn't require site-of-care documentation or administration codes.

ICD-10 Mapping for Medullary Thyroid Carcinoma

Primary Code: C73 (Malignant neoplasm of thyroid gland)

ICD-10 doesn't differentiate thyroid cancer subtypes, so medullary, papillary, and follicular cancers all use C73. Your documentation should specify "medullary thyroid carcinoma" in clinical notes even though the code is generic.

Supporting Documentation Words:

  • "Medullary thyroid carcinoma" or "MTC"
  • "Progressive" or "metastatic"
  • "Calcitonin elevation"
  • "RET mutation" (if applicable)
  • "Failed surgical resection" or "unresectable"

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Humana provider portal Humana policy
ICD-10 Code C73 for all thyroid cancers Clinical notes, pathology Cancer Therapy Advisor
Step Therapy May require other drug trials first Humana formulary Part D guidelines
Appeals Deadline 65 days from denial (Medicare) Denial letter CMS regulations
External Review Within 4 months of final denial Illinois DOI Illinois law

Product Coding: NDC Numbers and Billing

Cometriq NDC Numbers (verify with current packaging):

  • 20 mg capsules: 42386-118-06
  • 80 mg capsules: 42386-120-06

No HCPCS J-Code: Cometriq capsules don't have an assigned J-code as of 2024. Billing uses NDC numbers on pharmacy claims.

Typical Dosing for Coding:

  • Standard dose: 140 mg daily (one 20 mg + one 80 mg + one 80 mg capsule)
  • 28-day supply = 112 capsules total
  • Cash price reference: ~$18,938 for 112-capsule pack

Units and Quantity: Always specify exact capsule counts and strengths. Humana may deny if quantities don't match FDA-approved dosing or if tablet formulations are mistakenly requested instead of capsules.

Clean Prior Authorization Request Anatomy

Example PA Request Components:

  1. Patient Information
    • Humana member ID
    • Date of birth
    • Prescriber NPI and contact
  2. Clinical Documentation
    • Diagnosis: "Metastatic medullary thyroid carcinoma (ICD-10: C73)"
    • Pathology report confirming MTC histology
    • Imaging showing disease extent
    • Prior treatments attempted (surgery, radiation, other systemic therapies)
  3. Prescription Details
    • Drug: Cometriq (cabozantinib) capsules
    • Strength: 20 mg and 80 mg capsules
    • Dosing: 140 mg daily (specify capsule combination)
    • NDCs: 42386-118-06 and 42386-120-06
    • Quantity: 28-day supply
  4. Medical Necessity Statement
    • FDA-approved indication for progressive MTC
    • Clinical rationale for this specific patient
    • Expected monitoring plan
Clinician Corner: Include specific language like "progressive medullary thyroid carcinoma despite optimal surgical management" and reference FDA prescribing information for indication support.

Frequent Pitfalls to Avoid

Common Coding Mistakes:

  1. Wrong Formulation: Requesting Cabometyx tablets instead of Cometriq capsules
  2. Missing Subtype: Using only "thyroid cancer" without specifying medullary type in notes
  3. Incorrect Quantities: Not matching capsule counts to daily dosing requirements
  4. Generic ICD-10: Failing to document MTC specifically in clinical notes despite using C73

Documentation Gaps:

  • Missing pathology confirmation of medullary histology
  • Lack of progression documentation
  • Absent prior treatment history
  • No monitoring plan

Submission Errors:

  • Using outdated NDC numbers
  • Submitting to medical benefit instead of pharmacy
  • Missing prescriber attestation of medical necessity

Verification Steps with Humana

Before Submitting:

  1. Check Current Formulary Status
    • Visit Humana's Medicare Drug List
    • Confirm Cometriq is covered (typically specialty tier)
    • Note any quantity limits or step therapy requirements
  2. Verify PA Requirements
    • Call Humana provider services: number on insurance card
    • Confirm current prior authorization criteria
    • Ask about expedited review options for oncology
  3. Confirm Submission Method
    • Provider portal: most reliable
    • Fax: 877-486-2621 (verify current number)
    • Phone: for urgent/expedited requests

Cross-Check Resources:

  • Humana provider bulletins for policy updates
  • CMS formulary requirements for Part D plans
  • Illinois insurance department for appeal rights

Quick Audit Checklist

Pre-Submission Review:

✓ Correct drug name: Cometriq (not Cabometyx)
✓ Proper formulation: Capsules specified
✓ Accurate NDCs: Match current product labeling
✓ ICD-10 code: C73 documented
✓ MTC specification: "Medullary" in clinical notes
✓ Pathology report: Attached and confirms histology
✓ Prior treatments: Documented with outcomes
✓ Dosing rationale: 140 mg daily justified
✓ Prescriber information: NPI and contact complete
✓ Member details: ID and demographics accurate

Quality Check:

  • All required fields completed
  • Supporting documents attached
  • Submission method confirmed
  • Follow-up plan established

Appeals Playbook for Illinois

Level 1: Internal Appeal with Humana

  • Timeline: 65 days from denial notice
  • How to file: Humana member portal or call number on insurance card
  • Required: Clinical documentation, denial letter, prescriber support
  • Decision time: 30 days standard, 72 hours expedited

Level 2: External Review (Illinois)

  • When: After internal appeal denial or if urgent
  • Timeline: Within 4 months of final internal denial
  • How to file: Illinois Department of Insurance
  • Cost: Free to patient
  • Decision time: 30 days standard, 24-72 hours expedited

Expedited Appeals: Available when delay could "seriously jeopardize" health. For progressive cancer, this often qualifies. Include physician statement about urgency.

Illinois-Specific Rights:

  • Independent physician reviewer (no conflicts of interest)
  • Binding external review decisions
  • State oversight through Illinois DOI
  • Consumer assistance: 877-527-9431
From our advocates: We've seen Illinois external reviews succeed when the internal appeal included strong clinical documentation but was denied on formulary technicalities. The independent physician reviewer focused on medical necessity rather than administrative barriers, leading to approval within the 30-day window.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Not FDA-approved for indication Submit FDA label showing MTC indication; include prescribing information link
Step therapy not completed Document contraindications or failures of required alternatives; request exception
Quantity exceeds limits Provide dosing rationale; cite FDA-approved 140 mg daily dosing
Non-formulary drug Request formulary exception with medical necessity documentation
Experimental/investigational Emphasize FDA approval; distinguish from off-label uses
Wrong formulation requested Clarify Cometriq capsules vs. Cabometyx tablets; provide correct NDCs

Key Documentation for Overturns:

  • Pathology report confirming MTC
  • Imaging showing disease progression
  • Prior treatment timeline with outcomes
  • Prescriber letter explaining medical necessity
  • FDA prescribing information for indication support

FAQ

How long does Humana prior authorization take for Cometriq in Illinois? Standard reviews take up to 30 days, but expedited reviews for oncology can be completed in 72 hours if urgency is documented.

What if Cometriq is non-formulary on my Humana plan? You can request a formulary exception with medical necessity documentation. Illinois law provides external review rights if the exception is denied.

Can I request an expedited appeal for cancer treatment? Yes. Progressive cancer often qualifies for expedited review. Include physician documentation of how delays could harm your health.

Does step therapy apply if I failed treatments in another state? Yes, documented treatment failures from any location should satisfy step therapy requirements. Provide complete medical records.

What's the difference between Cometriq and Cabometyx for coverage? They're different formulations for different cancers. Cometriq capsules are specifically for MTC; mixing them up is a common denial trigger.

Who can help if my appeal is denied? Contact the Illinois Department of Insurance at 877-527-9431 or the Illinois Attorney General's Health Care Helpline at 877-305-5145.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and procedural requirements, making the appeals process more efficient and effective.

Getting Cometriq covered requires attention to coding details, proper documentation, and understanding your appeal rights in Illinois. With the right preparation and persistence, patients can successfully navigate Humana's prior authorization process and access this important cancer treatment. Counterforce Health's systematic approach to appeals can help streamline this complex process when denials occur.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For assistance with insurance appeals in Illinois, contact the Illinois Department of Insurance at 877-527-9431.

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