By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by UnitedHealthcare in Washington: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Cometriq Covered by UnitedHealthcare in Washington

Fastest path to approval: Submit prior authorization through UnitedHealthcare's provider portal with complete medical records documenting medullary thyroid carcinoma diagnosis, progression status, and treatment history. If denied, pursue internal appeals (180 days) followed by Washington's Independent Review Organization (IRO) external review. Start today by having your oncologist initiate the PA request with supporting clinical documentation.

First step: Contact your prescribing oncologist to begin the prior authorization process through OptumRx, UnitedHealthcare's pharmacy benefit manager.

Table of Contents

  1. Understanding UnitedHealthcare's Cometriq Coverage
  2. Prior Authorization Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & Solutions
  5. Cost Management and Financial Assistance
  6. Appeals Process in Washington
  7. When to Escalate to State Regulators
  8. Frequently Asked Questions

Understanding UnitedHealthcare's Cometriq Coverage

Cometriq (cabozantinib) is typically placed on Tier 4 or Tier 5 of UnitedHealthcare formularies, requiring specialty pharmacy dispensing and prior authorization. The medication costs approximately $18,938 per month for a standard 140mg daily dose pack, making coverage approval critical for patient access.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all indications UHC PA Policy
Formulary Tier Tier 4-5 (specialty) UHC Commercial Formularies
Step Therapy Not required for medullary thyroid carcinoma UHC PA Policy
Specialty Pharmacy Required through OptumRx UHC Provider Guidelines
Appeals Deadline 180 days from denial Washington State Law

Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Cometriq through OptumRx. The good news: no step therapy is required for medullary thyroid carcinoma, the FDA-approved indication.

Medical Necessity Criteria

Your oncologist must document:

  • Confirmed diagnosis of progressive, metastatic medullary thyroid carcinoma
  • Disease progression or symptomatic disease requiring treatment
  • Appropriate dosing based on patient weight and tolerability
  • Monitoring plan for adverse effects
Clinician Corner: Include ICD-10 codes (C73 for malignant neoplasm of thyroid gland), recent imaging showing progression, and baseline laboratory values in your PA submission. Reference the FDA prescribing information for dosing justification.

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Complete medical records from oncology visits
    • Recent imaging studies showing disease progression
    • Laboratory results (baseline liver function, blood counts)
  2. Submit Prior Authorization (Prescriber)
    • Use UnitedHealthcare Provider Portal or call OptumRx
    • Include completed PA form with clinical rationale
    • Expected timeline: 3-5 business days for standard review
  3. Monitor Status (Patient/Clinic)
    • Check portal daily for updates
    • Respond promptly to requests for additional information
    • Request peer-to-peer review if initial denial occurs
  4. Pharmacy Coordination (Patient)
    • Enroll with OptumRx specialty pharmacy
    • Complete financial assistance applications
    • Coordinate delivery and administration timing

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient clinical information Resubmit with complete records Oncology notes, imaging, labs
Missing diagnosis code Add ICD-10 C73 Pathology report, clinical notes
Dosing concerns Provide weight-based justification Patient weight, FDA dosing guidelines
Alternative therapy not tried Document contraindications Medical records showing intolerance

Most frequent error: Confusion between Cometriq (cabozantinib capsules) and Cabometyx (cabozantinib tablets). These are not interchangeable formulations. Ensure your prescription specifically requests Cometriq capsules.

Cost Management and Financial Assistance

Manufacturer Support Programs

Exelixis Access Services (EASE) offers significant cost assistance:

  • Commercial Insurance Patients: Copay card reduces out-of-pocket to as low as $0 per month
  • Uninsured/Underinsured: Free drug program based on financial need
  • Eligibility: Not available for government insurance (Medicare, Medicaid, VA)

Apply at ease.us or through your healthcare provider.

Specialty Pharmacy vs. Retail

Cometriq must be dispensed through specialty pharmacy due to its classification. OptumRx specialty pharmacy typically offers:

  • Coordinated prior authorization support
  • Clinical monitoring and adherence programs
  • Potential cost advantages through negotiated pricing
Tip: Enroll in manufacturer programs before your first fill to maximize savings from day one.

Counterforce Health helps patients navigate complex prior authorization requirements by analyzing denial letters and crafting targeted appeals with evidence-based medical justifications. Their platform specializes in turning insurance denials into successful approvals for specialty medications like Cometriq.

Appeals Process in Washington

Washington State provides robust appeal rights with multiple levels of review.

Internal Appeals Timeline

  • First Level: 180 days from denial notice
  • Submit via: UnitedHealthcare member portal, mail, or fax
  • Decision timeframe: 30 days (72 hours for urgent cases)
  • Required documents: Denial letter, supporting medical records, physician letter

External Review (IRO)

If internal appeals are unsuccessful, Washington law guarantees Independent Review Organization (IRO) review:

  • Timeline: 180 days from final internal denial
  • Process: Submit request to Washington Office of the Insurance Commissioner
  • Decision: Binding on UnitedHealthcare within 30 days
  • Cost: No charge to patient

Success rates: While specific data for Cometriq denials isn't published, IRO reviews overturn approximately 30-50% of insurer denials nationally.

Appeals Playbook

  1. Internal Appeal
  2. External Review

When to Escalate to State Regulators

Contact the Washington State Office of the Insurance Commissioner if:

  • UnitedHealthcare fails to respond within required timeframes
  • You encounter procedural barriers to filing appeals
  • The insurer requests inappropriate or excessive documentation

Consumer Advocacy Line: 800-562-6900 Online complaint: Washington Insurance Commissioner website

From our advocates: We've seen cases where patients initially denied Cometriq coverage successfully obtained approval after providing additional clinical context about disease progression and treatment urgency. The key was demonstrating that the medication met FDA-approved criteria and that delay could impact treatment outcomes. This represents a composite of successful appeal strategies, not a guarantee of results.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Cometriq? Standard review takes 3-5 business days. Urgent cases can be expedited to 24-72 hours with proper medical justification.

What if Cometriq is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and lack of suitable alternatives.

Can I request expedited appeal in Washington? Yes, if delay could seriously jeopardize your health. Provide supporting physician documentation with your expedited request.

Does step therapy apply if I haven't tried other treatments? No step therapy is required for FDA-approved medullary thyroid carcinoma indication. For off-label uses, step therapy may apply.

What's the difference between Cometriq and Cabometyx? Cometriq (capsules) and Cabometyx (tablets) are different formulations and are not interchangeable. Ensure your prescription specifies Cometriq capsules.

How much will I pay out-of-pocket? With Tier 4-5 placement, expect 20-50% coinsurance. Manufacturer copay programs can reduce this to $0 for eligible commercial insurance patients.

What happens if my appeal is denied? You can request Washington's IRO external review, which provides an independent medical expert evaluation that's binding on UnitedHealthcare.

Can Counterforce Health help with my appeal? Counterforce Health specializes in analyzing insurance denials and creating targeted appeals for specialty medications, helping transform denials into approvals through evidence-based advocacy.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Coverage policies may change, and individual circumstances vary.

Sources & Further Reading

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