By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by UnitedHealthcare in North Carolina: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Cometriq Covered by UnitedHealthcare in North Carolina

UnitedHealthcare requires prior authorization for Cometriq (cabozantinib capsules) in North Carolina, primarily for progressive, metastatic medullary thyroid cancer (MTC). Submit PA through your oncologist via the UHC Provider Portal with pathology reports, imaging showing progression, and ICD-10 codes. If denied, you have 180 days to file an internal appeal, then can request external review through North Carolina's Smart NC program within 120 days.

First step today: Call your oncologist's office to confirm they'll submit the PA 3-4 weeks before you need treatment, and verify your plan covers specialty drugs through OptumRx.

Table of Contents

  1. Plan Types & Network Requirements
  2. Formulary Status & Coverage Criteria
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Setup
  5. Appeals Process for North Carolina
  6. Common Denial Reasons & Solutions
  7. Cost-Sharing & Financial Assistance
  8. When to Escalate
  9. Frequently Asked Questions

Plan Types & Network Requirements

UnitedHealthcare offers several plan types in North Carolina, each with different rules for accessing oncology specialists and specialty drugs like Cometriq:

Plan Type PCP Required? Referral for Oncology? Out-of-Network Coverage?
HMO Yes Yes, via PCP No
PPO No (recommended) No Yes (higher costs)
EPO No Often via PCP No
Note: If you have an HMO plan, you'll need a primary care provider referral before seeing an oncologist. This can add 1-2 weeks to your timeline, so factor this into your planning.

For specialty drugs like Cometriq, all UnitedHealthcare plans typically route prescriptions through OptumRx Specialty Pharmacy, regardless of plan type.

Formulary Status & Coverage Criteria

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all plans UHC Provider Portal
Formulary Tier Specialty tier (4-5) 2024 Essential Plus PDL
Quantity Limit 30-day supply standard Plan formulary
Diagnosis Required Progressive, metastatic MTC PA Notification Form

Cometriq is listed on UnitedHealthcare's formulary but requires prior authorization across commercial plans. The drug is specifically approved for progressive, metastatic medullary thyroid cancer, with initial authorization lasting 12 months.

Important: Cometriq capsules are NOT interchangeable with Cabometyx tablets. Make sure your prescription specifies the capsule formulation to avoid automatic denials.

Prior Authorization Requirements

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Pathology report confirming MTC diagnosis
    • Imaging showing disease progression
    • ICD-10 codes for metastatic MTC
    • Performance status assessment
    • Timeline: 1-2 weeks
  2. Submit PA Request (Oncologist Only)
    • Use UHC Provider Portal
    • Include medical necessity letter referencing NCCN guidelines
    • Timeline: Submit 3-4 weeks before treatment start
  3. Monitor Decision (Patient/Clinic)
    • Standard decision: 72 hours
    • Check portal daily or call 866-889-8054
    • Timeline: 3 business days

Medical Necessity Documentation

UnitedHealthcare's coverage criteria mandate:

  • Confirmed MTC diagnosis via pathology
  • Distant metastatic disease documented clinically/radiographically
  • Disease progression on imaging
  • FDA-approved dosing (capsules, not tablets)
Clinician Corner: Your medical necessity letter should reference the FDA labeling for Cometriq and include progression dates from imaging reports. NCCN guidelines also support cabozantinib for medullary thyroid carcinoma.

Specialty Pharmacy Setup

UnitedHealthcare routes Cometriq through OptumRx Specialty Pharmacy since it's a self-administered oral oncology drug requiring special handling.

Patient Setup Process

  1. Contact OptumRx Specialty
  2. Transfer Prescription
    • Provide medical history and insurance details
    • Verify prior authorization status
    • Set up delivery preferences
  3. Enroll in Support Programs
    • Pharmacist consultations
    • Adherence monitoring
    • Financial assistance screening

Fulfillment: OptumRx ships directly to your home with special packaging for temperature-sensitive medications. Retail pharmacies cannot dispense Cometriq.

Appeals Process for North Carolina

If UnitedHealthcare denies your Cometriq prior authorization, North Carolina offers strong consumer protections through a two-level internal appeal process followed by external review.

Internal Appeals Timeline

Level Filing Deadline Decision Timeline How to Submit
First Appeal 180 days from denial 30 days (72 hours expedited) UHC Member Portal or denial letter instructions
Second Appeal 60 days from first denial 30 days Same as first appeal
Peer-to-Peer Immediately after denial During business hours Provider services call

External Review (Smart NC)

After exhausting internal appeals, North Carolina's Smart NC program provides independent review:

  • Filing deadline: 120 days from final internal denial
  • Decision timeline: 45 days standard, 72 hours expedited
  • Success rate: Over 50% of denials overturned
  • Contact: 1-855-408-1212 (free advocacy support)
Tip: Smart NC staff can help you gather medical records and complete the external review request form. This service is free for North Carolina residents with state-regulated insurance plans.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Wrong formulation (Cabometyx vs. Cometriq) Resubmit with correct capsule prescription New prescription specifying "cabozantinib capsules"
Missing MTC diagnosis Provide pathology report Biopsy results with ICD-10 codes
Off-label use Demonstrate FDA-approved indication Medical records showing metastatic MTC
Insufficient progression Submit recent imaging Radiology reports with progression dates

Most common error: Prescriptions written for Cabometyx tablets instead of Cometriq capsules. Always verify the correct formulation with your oncologist.

Cost-Sharing & Financial Assistance

Cometriq's cash price averages $18,938 for a 112-capsule pack (140 mg daily dose), making financial assistance crucial for most patients.

Available Support Options

  • Exelixis Patient Assistance: Contact manufacturer directly for eligibility
  • OptumRx Copay Programs: Available through specialty pharmacy enrollment
  • North Carolina State Programs: Check eligibility for additional state assistance
  • Clinical Trials: Alternative access through research participation
Note: Specialty tier medications typically require 20-40% coinsurance after deductible. Review your specific plan's Evidence of Coverage for exact cost-sharing details.

When to Escalate

If internal and external appeals fail, contact:

  • North Carolina Department of Insurance: File a complaint if procedural violations occurred
  • UnitedHealthcare Member Services: 1-888-636-4540 for plan-specific questions
  • Smart NC Helpline: 1-855-408-1212 for ongoing advocacy support

Consider working with specialized services like Counterforce Health, which helps patients navigate complex prior authorization and appeals processes by turning insurance denials into targeted, evidence-backed appeals.

Frequently Asked Questions

Q: How long does UnitedHealthcare prior authorization take in North Carolina? A: Standard decisions come within 72 hours (3 business days). Expedited requests for urgent cases are decided within 72 hours.

Q: What if Cometriq is non-formulary on my specific plan? A: Request a formulary exception through the same PA process. Include documentation showing medical necessity and lack of formulary alternatives.

Q: Can I request an expedited appeal for cancer treatment? A: Yes. Both UnitedHealthcare internal appeals and North Carolina's external review offer expedited timelines for urgent medical situations.

Q: Does step therapy apply if I haven't tried other treatments? A: UnitedHealthcare may require documentation of prior therapies or contraindications. Your oncologist should address this in the medical necessity letter.

Q: What's the difference between HMO and PPO coverage for Cometriq? A: Prior authorization requirements are the same, but HMO plans require PCP referrals to oncology, potentially adding 1-2 weeks to your timeline.

When facing a rare cancer diagnosis like medullary thyroid carcinoma, navigating insurance coverage shouldn't add to your stress. Counterforce Health specializes in helping patients get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals, ensuring you can focus on your treatment rather than paperwork battles.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for decisions about your specific situation. For additional help with North Carolina insurance appeals, contact Smart NC at 1-855-408-1212.

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