By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Humana in New York: Complete Prior Authorization Guide

Answer Box: Getting Cometriq Covered by Humana in New York

Cometriq (cabozantinib) requires prior authorization from Humana Medicare Advantage and Part D plans. Your oncologist must submit documentation proving progressive, metastatic medullary thyroid carcinoma (ICD-10: C73) with evidence the disease isn't surgically curable. Fastest path: Have your oncologist gather pathology reports, imaging showing progression, and prior treatment history, then submit through Humana's provider portal. Standard approval takes up to 30 days; expedited review available within 72 hours for urgent cases. If denied, New York residents can file an external appeal through the Department of Financial Services within 4 months.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Request
  5. Follow-Up and Tracking
  6. Typical Timelines
  7. If You're Asked for More Information
  8. If Your Request Is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps patients with medullary thyroid carcinoma and their healthcare teams navigate Humana's prior authorization process for Cometriq (cabozantinib capsules) in New York. You'll learn exactly what documentation to gather, how to submit requests efficiently, and what to do if you face a denial.

Important: Cometriq capsules are not interchangeable with Cabometyx tablets. The FDA explicitly states these formulations cannot be substituted due to different bioavailability profiles. Make sure your prescription specifies the capsule formulation.

Before You Start: Verify Your Coverage

Check Your Plan Type

  • Humana Medicare Advantage: Prior authorization required through medical benefit
  • Humana Part D: Prior authorization required through pharmacy benefit
  • Commercial Humana: Requirements vary by employer group

Confirm Formulary Status

Visit Humana's drug list tool to verify Cometriq's tier placement on your specific plan. Most plans classify it as Tier 5 (specialty), requiring higher copays or coinsurance.

Verify Specialty Pharmacy Requirements

Cometriq must be dispensed through Humana's in-network specialty pharmacy network for Part D patients. Your retail pharmacy cannot fill this prescription without prior authorization approval.

Gather What You Need

Clinical Documentation Required

Document Type Specific Requirements Where to Find
Diagnosis Confirmation Pathology report showing medullary thyroid carcinoma Hospital pathology department
ICD-10 Code C73 (Malignant neoplasm of thyroid gland) Provider's clinical notes
Disease Progression Recent imaging (CT, MRI, or PET scan) showing metastatic disease Radiology department
Surgical Consultation Documentation that disease is not amenable to curative surgery Surgical oncologist notes
Prior Treatments List of previous therapies tried and outcomes Oncology treatment records
Prescriber Credentials Oncologist license and contact information Provider's office

Patient Information Needed

  • Full name and date of birth
  • Humana member ID number
  • Policy/group number
  • Prescriber's name, NPI, and contact details
  • Requested dosing regimen (typically 140 mg daily)
Tip: Request all medical records at least one week before your oncologist plans to submit the prior authorization. Processing delays often occur when documentation is incomplete.

Submit the Request

Step-by-Step Submission Process

  1. Oncologist Reviews Clinical Criteria
    • Confirm progressive, metastatic medullary thyroid carcinoma diagnosis
    • Verify patient is 18+ years old
    • Document that curative surgery is not an option
    • Check for contraindications (recent hemorrhage, uncontrolled hypertension)
  2. Complete Prior Authorization Form
  3. Attach Required Documentation
    • Medical necessity letter from oncologist
    • Pathology report confirming MTC
    • Recent imaging studies
    • Surgical consultation notes
    • Prior treatment history
  4. Submit Complete Package
    • Use Humana's online portal for fastest processing
    • Keep confirmation number for tracking
    • Send via secure fax if portal unavailable

Medical Necessity Letter Checklist

Your oncologist's letter should include:

  • Patient's specific diagnosis with ICD-10 code C73
  • Evidence of metastatic/progressive disease
  • Explanation why surgery is not curative
  • Previous treatments attempted and results
  • Clinical rationale for Cometriq therapy
  • Proposed dosing and monitoring plan
  • Reference to FDA-approved indication

Follow-Up and Tracking

Monitor Your Request Status

  • Online: Log into your Humana member portal
  • Phone: Call customer service at 1-800-281-6918
  • Provider portal: Your oncologist can track through their account

When to Call

  • 5 business days after submission if no acknowledgment
  • 15 days after submission for status update
  • Immediately if you receive a request for additional information

Sample Phone Script

"I'm calling to check the status of a prior authorization request for Cometriq submitted on [date]. My member ID is [number] and the reference number is [confirmation number]. Can you tell me the current status and expected decision date?"

Typical Timelines

New York-Specific Requirements

Review Type Humana Timeline New York Law
Standard PA (Medicare Advantage) Up to 30 days Must comply with CMS requirements
Standard PA (Part D) Up to 7 days State oversight applies
Expedited Review 72 hours 72 hours for urgent cases
Expedited Drug Appeals 72 hours 24 hours for non-formulary drugs

What Speeds Up Decisions

  • Complete documentation submitted initially
  • Clear medical necessity letter
  • Oncologist available for peer-to-peer review
  • Proper ICD-10 coding (C73)

What Slows Down Decisions

  • Missing pathology reports
  • Unclear surgical consultation notes
  • Incomplete prior treatment history
  • Wrong formulation specified (tablets vs. capsules)

If You're Asked for More Information

Common Additional Requests

  1. More detailed imaging reports: Submit full radiology reports, not just summaries
  2. Surgical consultation clarification: Obtain specific statement about non-resectability
  3. Prior therapy documentation: Provide detailed treatment timelines and outcomes
  4. Contraindication screening: Submit recent labs and vital signs

Responding Quickly

  • Humana typically allows 14 days to provide additional information
  • Submit via the same method as original request
  • Include original reference number
  • Follow up within 2 business days to confirm receipt
From Our Advocates: We've seen cases where patients received approval after initially being asked for "more information." The key is responding promptly with exactly what's requested—don't send extra documentation that wasn't specifically asked for, as this can slow the review process.

If Your Request Is Denied

Understanding Common Denial Reasons

Denial Code/Reason How to Address
"Not FDA-approved indication" Confirm MTC diagnosis; attach FDA label showing approved use
"Alternative therapy required first" Document contraindications to alternatives or prior failures
"Insufficient medical necessity" Provide more detailed progression evidence and surgical consultation
"Wrong formulation" Clarify that capsules (not tablets) are required for MTC

Internal Appeal Process

  1. File within 60 days of denial notice
  2. Submit through same portal used for original request
  3. Include new supporting evidence if available
  4. Request peer-to-peer review with Humana's medical director

External Appeal in New York

If Humana upholds the denial, New York residents have strong appeal rights:

  • File with NY Department of Financial Services within 4 months
  • Expedited review available for oncology medications (72-hour decision)
  • Independent medical review by external experts
  • Binding decision that Humana must follow
  • $25 maximum fee (waived for financial hardship)

For help with external appeals, contact Community Health Advocates at 888-614-5400—they provide free assistance to New York residents.

Renewal and Re-Authorization

When to Resubmit

  • Most Cometriq approvals are granted for 6-12 months
  • Calendar renewal date 30 days before expiration
  • Don't wait for denial notice to start renewal process

Renewal Documentation

  • Updated imaging showing continued progression or stable disease
  • Treatment response documentation
  • Continued medical necessity letter
  • Any new relevant clinical trials or guidelines

Streamlining Renewals

  • Keep digital copies of all original approval documentation
  • Update only what has changed since last approval
  • Submit 30-45 days before current authorization expires

Quick Reference Checklist

Before Submitting:

  • Confirmed MTC diagnosis with pathology report
  • Recent imaging showing metastatic/progressive disease
  • Surgical consultation documenting non-resectability
  • ICD-10 code C73 in medical records
  • Prior treatment history documented
  • Prescription specifies capsules (not tablets)
  • Humana member ID and policy information ready

After Submitting:

  • Confirmation number received and saved
  • Follow-up call scheduled for 5 business days
  • Provider portal access confirmed for tracking
  • Additional information request process understood
  • Appeal deadlines noted (60 days internal, 4 months external)

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and procedural requirements. Learn more about our prior authorization support.

Frequently Asked Questions

How long does Humana prior authorization take for Cometriq in New York?
Standard reviews take up to 30 days for Medicare Advantage plans and 7 days for Part D plans. Expedited reviews are completed within 72 hours if urgency is demonstrated.

What if Cometriq isn't on my Humana formulary?
You can request a formulary exception with strong medical necessity documentation. New York law requires expedited review (24 hours) for non-formulary drug requests in urgent situations.

Can I get Cometriq from any pharmacy with Humana coverage?
No. Cometriq must be dispensed through Humana's in-network specialty pharmacy network for Part D patients. Your oncologist's office can help coordinate this.

What's the difference between Cometriq and Cabometyx for insurance purposes?
These are not interchangeable formulations. Cometriq (capsules) is approved for medullary thyroid cancer, while Cabometyx (tablets) treats different cancer types. Insurance coverage is indication-specific.

Does step therapy apply to Cometriq in New York?
Step therapy requirements vary by plan. If required, you can request an exception based on contraindications to first-line therapies or documented failures with previous treatments.

How much will Cometriq cost with Humana coverage?
As a Tier 5 specialty drug, expect higher copays or coinsurance. Check your specific plan documents or contact Humana for exact costs. Manufacturer copay assistance may be available.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan terms and clinical circumstances. Consult your healthcare provider and insurance plan for specific guidance. For additional help with insurance appeals in New York, contact the Community Health Advocates helpline at 888-614-5400 or visit the NY Department of Financial Services website.

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