By Counterforce Health Team in Cometriq (cabozantinib) —

Myths vs. Facts: Getting Cometriq (Cabozantinib) Covered by Aetna (CVS Health) in Florida

Answer Box: Getting Cometriq (Cabozantinib) Covered by Aetna (CVS Health) in Florida

Eligibility: Aetna covers Cometriq (cabozantinib capsules) for metastatic medullary thyroid carcinoma with prior authorization. Fastest path: Submit PA with confirmed MTC diagnosis, elevated calcitonin levels, and imaging showing metastatic disease. First step today: Verify your plan's formulary status and gather pathology reports. Appeals must be filed within 180 days in Florida, with external review available if denied.

Table of Contents

  1. Why Myths About Cometriq Coverage Persist
  2. Myth vs. Fact: Common Misconceptions
  3. What Actually Influences Approval
  4. Avoid These Critical Mistakes
  5. Quick Action Plan: Three Steps to Take Today
  6. FAQ: Your Most Pressing Questions
  7. Resources and Support

Why Myths About Cometriq Coverage Persist

When facing a rare cancer diagnosis like medullary thyroid carcinoma (MTC), patients and families often rely on outdated information, well-meaning but incorrect advice from online forums, or assumptions based on other cancer treatments. The reality is that Cometriq (cabozantinib capsules) has very specific coverage requirements that differ significantly from its tablet counterpart, Cabometyx.

These myths can cost you valuable time—and in some cases, lead to preventable denials that delay life-saving treatment. Let's separate fact from fiction so you can navigate Aetna's approval process with confidence.

Myth vs. Fact: Common Misconceptions

Myth 1: "If my oncologist prescribes Cometriq, Aetna has to cover it"

Fact: Even with a prescription, Aetna requires prior authorization for Cometriq and will only approve it for FDA-indicated uses. Your doctor's prescription is just the starting point—you need comprehensive documentation proving medical necessity for metastatic MTC specifically.

Myth 2: "Cometriq and Cabometyx are the same, so I can substitute one for the other"

Fact: This is one of the most dangerous misconceptions. Cometriq (capsules) is FDA-approved only for metastatic medullary thyroid carcinoma, while Cabometyx (tablets) covers different cancers like kidney and liver cancer. Attempting to substitute formulations will result in automatic denial.

Myth 3: "I can appeal forever if Aetna denies my claim"

Fact: Florida law gives you exactly 180 days from the denial notice to file your internal appeal. Miss this deadline, and you lose your right to challenge the decision. After internal appeal, you have 120 days to request external review.

Myth 4: "Generic alternatives are always required first"

Fact: There is no generic version of cabozantinib. However, Aetna may require you to try vandetanib first (step therapy) unless your doctor documents contraindications, intolerance, or clinical reasons why Cometriq is superior for your specific case.

Myth 5: "Prior authorization is just a formality—it always gets approved"

Fact: Specialty drug denials are common, especially when documentation is incomplete. Aetna's clinical reviewers scrutinize every detail, from your exact diagnosis codes to proof of disease progression.

Myth 6: "I need to pay out-of-pocket while waiting for approval"

Fact: Never pay cash prices (~$18,938 per month) while your appeal is pending. Exelixis offers patient assistance programs that can provide temporary access, and Florida law requires expedited appeals for urgent medical situations.

Myth 7: "All Aetna plans have the same coverage rules"

Fact: Self-funded employer plans may have different formularies and step therapy requirements than standard Aetna policies. Always verify your specific plan's coverage by calling the member services number on your insurance card.

What Actually Influences Approval

Understanding what Aetna's clinical reviewers actually look for can dramatically improve your approval odds:

Essential Documentation Requirements

Pathology Confirmation: Synoptic pathology report following CAP protocols showing confirmed MTC diagnosis from either fine needle aspiration or surgical resection.

Tumor Markers: Elevated serum calcitonin and/or CEA levels demonstrating neuroendocrine origin of your cancer.

Imaging Evidence: Reports from thyroid ultrasound, CT, MRI, or PET/CT clearly documenting metastatic disease extent.

Genetic Testing: RET proto-oncogene mutation status, especially important for hereditary MTC cases.

Clinical Criteria That Matter

Aetna's reviewers focus on three key questions:

  1. Is this truly metastatic MTC as defined by FDA labeling?
  2. Has the patient progressed despite standard care or are they unsuitable for other treatments?
  3. Is there clear evidence of medical necessity for this specific formulation?

Routing and Submission Process

Submit prior authorization requests via Availity portal for fastest processing (24-72 hours) or fax to 1-866-249-6155. Standard mail submissions can take 5-10 business days just for processing.

Avoid These Critical Mistakes

1. Submitting Incomplete Documentation

The mistake: Sending only a prescription without supporting clinical evidence.

The fix: Create a comprehensive packet including pathology reports, tumor markers, imaging studies, genetic testing results, and a detailed medical necessity letter from your oncologist.

2. Using Wrong Diagnosis Codes

The mistake: Submitting claims with generic thyroid cancer codes instead of specific MTC codes.

The fix: Ensure your oncologist uses the correct ICD-10 code for medullary thyroid carcinoma and includes documentation of metastatic disease.

3. Missing Florida-Specific Deadlines

The mistake: Assuming you have unlimited time to appeal.

The fix: Mark your calendar immediately—you have 180 days from denial to appeal internally, then 120 days to request external review through Florida's Department of Financial Services.

4. Not Requesting Expedited Review When Appropriate

The mistake: Accepting standard 30-day review timelines when your condition is urgent.

The fix: If delaying treatment could worsen your condition, explicitly request expedited review. Aetna must respond within 72 hours for urgent cases.

5. Paying Cash While Appeals Are Pending

The mistake: Assuming you must pay out-of-pocket during the review process.

The fix: Contact Exelixis Access Services at 1-855-EXELIXIS for patient assistance programs, and ask your oncologist about clinical trial options or compassionate use programs.

Quick Action Plan: Three Steps to Take Today

Step 1: Verify Your Coverage (15 minutes)

Call the member services number on your Aetna insurance card and ask:

  • "Is Cometriq on my plan's formulary?"
  • "What tier is it on, and what's my copay?"
  • "Do I need prior authorization?"
  • "Are there step therapy requirements?"

Step 2: Gather Essential Documentation (1-2 hours)

Contact your oncologist's office to request:

  • Complete pathology report with MTC confirmation
  • Latest calcitonin and CEA lab results
  • Most recent imaging reports showing disease extent
  • Genetic testing results (RET mutation status)
  • Treatment history and rationale for Cometriq

Step 3: Submit Prior Authorization (30 minutes)

Have your oncologist's office submit the PA request through Availity portal with all documentation attached. If they're not set up for electronic submission, use the fax number 1-866-249-6155.

From our advocates: We've seen cases where patients waited months for "the right time" to start the approval process, only to face delays that could have been avoided. One Florida patient with MTC had their initial PA denied because the oncologist's office submitted generic thyroid cancer codes instead of specific MTC documentation. After resubmission with proper coding and a detailed medical necessity letter, approval came within 48 hours. The key lesson: accuracy and completeness matter more than speed.

FAQ: Your Most Pressing Questions

Q: How long does Aetna prior authorization take for Cometriq in Florida?

A: Standard PA decisions come within 3-5 business days when submitted electronically. Expedited reviews for urgent cases are completed within 72 hours.

Q: What if Cometriq is non-formulary on my Aetna plan?

A: You can request a formulary exception by demonstrating medical necessity and showing why formulary alternatives (like vandetanib) are inappropriate for your case. Submit exception requests to the same PA fax line.

Q: Can I request an expedited appeal if Aetna denies my Cometriq?

A: Yes. If delaying treatment could seriously harm your health, you can request expedited internal appeals (72-hour decision) and expedited external review through Florida's process.

Q: Does step therapy apply if I've already failed vandetanib outside of Florida?

A: Documentation of prior vandetanib failure or intolerance should satisfy step therapy requirements regardless of where the trial occurred. Include complete records from your previous treatment.

Q: What's the difference between internal appeals and external review in Florida?

A: Internal appeals are reviewed by Aetna's own clinical staff within 30 days. If unsuccessful, external review involves independent medical experts contracted by Florida's Department of Financial Services, with binding decisions typically within 45 days.

Q: How much will Cometriq cost me if approved by Aetna?

A: Costs vary by plan, but specialty drugs like Cometriq typically fall on high tiers with significant copays. Contact Exelixis Access Services for copay assistance programs that may reduce your out-of-pocket costs to as little as $25 per month.

Resources and Support

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific basis for rejection, and drafts point-by-point rebuttals aligned to each payer's requirements. For complex cases like Cometriq approvals, having the right evidence and argumentation can make the difference between coverage and costly delays.

Official Resources

Contact Information

  • Aetna Specialty PA Line: 1-866-814-5506
  • CVS Caremark PA Fax: 1-866-249-6155
  • Florida Insurance Consumer Helpline: 1-877-693-5236
  • Exelixis Access Services: 1-855-EXELIXIS

When to Escalate

If you've exhausted internal appeals and external review without success, you can file a complaint with Florida's Office of Insurance Regulation. However, most Cometriq cases are resolved successfully when proper documentation is provided and Counterforce Health's systematic approach is used to address the specific denial reasons.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by individual plan. Always consult with your healthcare provider and insurance plan directly for the most current requirements and procedures specific to your situation.

Sources & Further Reading

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