By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (cabozantinib) Covered by UnitedHealthcare in Michigan: Complete PA Guide with Forms and Appeals

Getting Cometriq (cabozantinib) covered by UnitedHealthcare in Michigan requires prior authorization for metastatic medullary thyroid carcinoma (MTC) or progressive thyroid cancers after failed step therapy. Submit via the UHC Provider Portal with diagnosis confirmation, or call 866-889-8054. If denied, you have 180 days for internal appeals and 127 days for Michigan DIFS external review after UHC's final decision.

Table of Contents

  1. Coverage at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Required Forms and Submission Methods
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Process for Michigan Patients
  6. Clinician Corner: Medical Necessity Letters
  7. When to Contact Michigan DIFS
  8. Specialty Pharmacy Requirements
  9. Cost Assistance Options
  10. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Cometriq prescriptions UHC PA Requirements UHC Policy
Formulary Status Covered with PA 2025 Michigan PDL UHC Michigan
Step Therapy Required for non-MTC indications PA Notification UHC Clinical
Specialty Pharmacy Must use UHC network pharmacy UHC Provider Portal UHC Network
Appeals Deadline 180 days from denial Member handbook UHC Policy
External Review 127 days after final UHC denial Michigan DIFS Michigan Law

Step-by-Step: Fastest Path to Approval

1. Verify Your UHC Plan Coverage

Who: Patient or clinic staff
Document needed: Insurance card, member ID
How to submit: Call member services or check UHC Provider Portal
Timeline: Immediate

2. Gather Required Documentation

Who: Prescribing oncologist
Documents needed:

  • Pathology report confirming medullary thyroid carcinoma
  • Imaging showing metastatic disease
  • For non-MTC: Prior therapy failure records (lenvatinib/Lenvima or sorafenib/Nexavar)
  • Current treatment plan

3. Submit Prior Authorization

Who: Healthcare provider
Method: UHC Provider Portal (preferred) or fax 866-889-8054
Timeline: 15-30 days standard, 72 hours expedited
Required: ICD-10 codes, diagnosis confirmation, treatment history

4. Specify Cometriq Capsules (Not Cabometyx)

Critical detail: Cometriq capsules are NOT interchangeable with Cabometyx tablets
Include: Exact NDC numbers and dosing schedule
Source: FDA labeling differences

5. Follow Up Within 5 Business Days

Action: Check PA status via provider portal
If no response: Call OptumRx at 866-889-8054
Escalation: Request peer-to-peer review if initial denial

Required Forms and Submission Methods

UnitedHealthcare Community Plan (Michigan Medicaid)

Commercial Plans

  • Primary method: UHC Provider Portal
  • Phone: 866-889-8054 (OptumRx)
  • Required login: One Healthcare ID (register at uhcprovider.com/access)
Tip: Online submissions process faster than fax. The provider portal allows real-time status tracking and document uploads.

Documentation Checklist

  • Completed PA request form
  • Pathology report with MTC diagnosis
  • Imaging studies showing progression/metastases
  • Prior medication trial records (if non-MTC)
  • Current prescription with exact Cometriq capsule strength
  • Medical necessity letter from oncologist

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Wrong formulation requested" Resubmit specifying Cometriq capsules NDC numbers, FDA labeling citation
"Step therapy not met" Document prior failures or contraindications Pharmacy records, side effect notes
"Diagnosis not confirmed" Provide pathology report Tissue biopsy results, ICD-10 C73
"Not medically necessary" Submit comprehensive medical necessity letter NCCN guidelines, progression evidence
"Missing prior authorization" Complete PA process All required forms and documentation

Appeals Process for Michigan Patients

Internal Appeals (Required First Step)

  1. Timeline: 180 days from denial date
  2. Method: UHC Provider Portal or written appeal
  3. Include:
    • Original denial letter
    • Additional medical evidence
    • Updated medical necessity letter
    • NCCN guideline citations

Expedited Appeals (Urgent Cases)

  • Timeline: 72 hours for decisions
  • Eligibility: Life-threatening situations or significant health deterioration
  • Required: Physician letter stating urgency

Michigan External Review

After exhausting UHC's internal appeals, Michigan patients can file with the Department of Insurance and Financial Services (DIFS).

Timeline: 127 days from UHC's final adverse determination
Form: FIS 0018 External Review Request
Submission: Online at DIFS portal or mail/fax
Cost: Free to patients
Decision timeline: 60 days standard, 72 hours expedited

Note: DIFS external review decisions are binding on UnitedHealthcare. If approved, UHC must cover the treatment.

Clinician Corner: Medical Necessity Letters

Essential Elements for MTC Patients

  1. Diagnosis confirmation: Pathology report with calcitonin levels
  2. Disease progression: Imaging studies showing metastatic spread
  3. Treatment rationale: FDA approval for progressive, metastatic MTC
  4. Monitoring plan: Regular imaging and lab assessments

For Non-MTC Thyroid Cancers

  1. Prior therapy documentation:
    • Lenvatinib (Lenvima) trial and failure/intolerance
    • OR sorafenib (Nexavar) trial and failure/intolerance
  2. Disease characteristics:
    • Iodine-refractory status
    • Unresectable locoregional disease
    • Distant metastatic disease
    • Symptomatic progression

Key Citations to Include

  • FDA Cometriq labeling
  • NCCN Thyroid Carcinoma Guidelines (current version)
  • Relevant peer-reviewed studies supporting use

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-based rebuttals. Their platform helps clinicians create targeted medical necessity letters that address specific UnitedHealthcare criteria for Cometriq coverage.

When to Contact Michigan DIFS

Contact the Michigan Department of Insurance and Financial Services if:

  • UHC doesn't respond to appeals within required timeframes
  • You believe UHC is improperly applying their own policies
  • You need help understanding your appeal rights

DIFS Contact Information:

  • Phone: 877-999-6442 (M-F 8am-5pm)
  • Website: michigan.gov/difs
  • Consumer complaint portal available online

Specialty Pharmacy Requirements

UnitedHealthcare requires Cometriq to be dispensed through their specialty pharmacy network.

Network Pharmacies

  • Use the UHC Provider Portal to locate Michigan specialty pharmacies
  • OptumRx may be the designated specialty pharmacy
  • 28-day supply packaging is standard for oral oncology medications

Transfer Process

  1. UHC approves PA
  2. Prescription sent to network specialty pharmacy
  3. Pharmacy contacts patient for delivery coordination
  4. First fill often requires patient education call

Cost Assistance Options

Manufacturer Support

  • Exelixis Patient Support: Financial assistance programs available
  • Copay cards: May reduce out-of-pocket costs for commercial plans
  • Free drug programs: For uninsured or underinsured patients

State and Federal Programs

  • Michigan Medicaid: Full coverage with PA approval
  • Medicare Extra Help: Prescription drug cost assistance
  • 340B programs: Available at qualifying healthcare facilities
From our advocates: We've seen Michigan patients successfully overturn Cometriq denials by ensuring their oncologist clearly documents the specific capsule formulation requirement and includes progression imaging in the appeal. One common mistake is submitting generic "thyroid cancer" documentation without specifying the medullary subtype—specificity matters for UHC's automated review systems.

FAQ

How long does UnitedHealthcare PA take for Cometriq in Michigan?
Standard prior authorization decisions take 15-30 days. Expedited reviews for urgent cases are completed within 72 hours.

What if Cometriq is non-formulary on my UHC plan?
Cometriq is covered on UHC formularies with prior authorization. If you receive a non-formulary denial, request a formulary exception with medical necessity documentation.

Can I request an expedited appeal if UHC denies coverage?
Yes, if your oncologist certifies that delays would seriously jeopardize your health or ability to regain maximum function, you can request expedited review.

Does step therapy apply if I tried other medications outside Michigan?
Yes, prior therapy trials from any location count toward step therapy requirements. Provide pharmacy records and physician notes documenting the trials.

What's the difference between Cometriq and Cabometyx?
Cometriq (capsules) and Cabometyx (tablets) contain the same active ingredient (cabozantinib) but are NOT interchangeable due to different absorption profiles. Always specify Cometriq capsules for MTC.

How do I check my appeal status with UHC?
Log into the UHC Provider Portal or call member services. Appeals are tracked with reference numbers provided when you submit.

What if I miss the 127-day deadline for Michigan external review?
The 127-day deadline is firm under Michigan law. Contact DIFS immediately if you're approaching the deadline—they may provide guidance on exceptional circumstances.

Can Counterforce Health help with my UHC Cometriq denial?
Yes, Counterforce Health specializes in analyzing denial letters and crafting targeted appeals that address UHC's specific coverage criteria for oncology medications like Cometriq.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Appeal deadlines and requirements may change—verify current information with UnitedHealthcare and Michigan DIFS before taking action.

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