By Counterforce Health Team in Cometriq (cabozantinib) —

Myths vs. Facts: Getting Cometriq (Cabozantinib) Covered by Humana in Ohio

Answer Box: Cometriq Coverage by Humana in Ohio

Myth: If your doctor prescribes Cometriq, Humana automatically covers it. Fact: Prior authorization is required for all Humana plans, with specific clinical criteria for medullary thyroid cancer. The fastest path: ensure your oncologist submits complete documentation including pathology reports showing progressive, metastatic MTC (ICD-10: C73), disease progression imaging, and medical necessity letter. First step today: call Humana at 1-800-281-6918 to confirm your plan's formulary tier and PA requirements. If denied, Ohio residents have 180 days to request external review through the Ohio Department of Insurance.

Table of Contents

  1. Why Myths About Cometriq Coverage Persist
  2. Myth vs. Fact: The Top 8 Misconceptions
  3. What Actually Influences Approval
  4. Avoid These 5 Preventable Mistakes
  5. Quick Action Plan: 3 Steps to Take Today
  6. Ohio-Specific Appeals Process
  7. FAQ
  8. Resources

Why Myths About Cometriq Coverage Persist

Confusion around Cometriq (cabozantinib) coverage stems from several factors unique to this specialty oncology drug. First, many patients and even some providers don't realize that Cometriq capsules and Cabometyx tablets are not interchangeable formulations despite containing the same active ingredient. Insurance systems often flag this as a substitution error, leading to automatic denials.

Second, medullary thyroid cancer is a rare disease affecting fewer than 4% of all thyroid cancer patients, meaning many healthcare teams encounter it infrequently. This rarity creates knowledge gaps about proper documentation requirements and prior authorization criteria.

Finally, Humana's relatively low Medicare Advantage denial rate of 3.5% in 2023 gives patients false confidence that "everything gets approved." While Humana does approve most requests, specialty drugs like Cometriq require meticulous documentation to meet their Tier 5 coverage criteria.

At Counterforce Health, we help patients and clinicians navigate these complexities by turning insurance denials into targeted, evidence-backed appeals. Our platform identifies the specific denial basis and drafts point-by-point rebuttals aligned to each plan's own rules, pulling the right clinical evidence and procedural requirements for successful outcomes.

Myth vs. Fact: The Top 8 Misconceptions

Myth 1: "If my oncologist prescribes it, insurance will cover it"

Fact: Prior authorization is mandatory for Cometriq on all Humana plans. Your oncologist must submit specific clinical documentation proving medical necessity, including pathology reports confirming progressive, metastatic medullary thyroid carcinoma and evidence that curative surgery isn't an option.

Myth 2: "Cometriq and Cabometyx are the same drug, so either will be covered"

Fact: These formulations have different bioavailability profiles and FDA-approved indications. Cometriq (capsules) is specifically approved for medullary thyroid cancer, while Cabometyx (tablets) treats other cancers. Prescribing the wrong formulation triggers automatic denials.

Myth 3: "Medicare covers all cancer drugs automatically"

Fact: Even Medicare Advantage plans require prior authorization for specialty drugs. Humana classifies Cometriq as Tier 5 specialty, requiring both PA approval and use of their specialty pharmacy network for Part D coverage.

Myth 4: "I can appeal to Ohio right away if Humana denies coverage"

Fact: You must exhaust Humana's internal appeals process first. Ohio's external review is available only after completing internal appeals, and you have 180 days from the final internal denial to request external review through the Ohio Department of Insurance.

Myth 5: "Step therapy doesn't apply to rare cancer drugs"

Fact: Step therapy requirements vary by individual Humana plan. Some plans may require trying vandetanib first or documenting why other treatments failed before approving Cometriq. Check your specific formulary or request an exception with medical justification.

Myth 6: "Generic cabozantinib is available and cheaper"

Fact: No generic version of Cometriq exists. The drug costs approximately $18,938 for a 112-capsule supply. Manufacturer copay assistance may be available, but generic substitution isn't an option.

Myth 7: "Appeals take months and aren't worth pursuing"

Fact: Humana's standard review timeline is 30 days for Medicare Advantage, 7 days for Part D. Expedited appeals are decided within 72 hours for urgent situations. Ohio's external review adds another 30 days for standard cases.

Myth 8: "Off-label use for other thyroid cancers will be covered the same way"

Fact: Cometriq is FDA-approved specifically for progressive, metastatic medullary thyroid carcinoma. Off-label use for differentiated thyroid cancer or other tumor types requires additional medical necessity documentation and faces higher denial rates.

What Actually Influences Approval

Clinical Criteria That Matter

Humana's approval hinges on meeting specific clinical criteria documented in their pharmacy policy:

  • Diagnosis: Progressive, metastatic medullary thyroid carcinoma (ICD-10: C73)
  • Age: 18 years or older
  • Disease status: Not amenable to curative surgery
  • Prescriber: Oncologist or prescribed in consultation with oncologist
  • Contraindication screening: No recent hemorrhage or uncontrolled hypertension

Documentation That Speeds Approval

Essential documents your oncologist should submit:

  • Pathology report confirming medullary thyroid carcinoma
  • Recent imaging showing disease progression (CT, MRI, or PET scan)
  • Surgical consultation notes documenting non-resectable disease
  • Medical necessity letter with clinical rationale
  • Prior treatment history and outcomes

Pro tip: Counterforce Health helps ensure all required documentation is included in the initial submission, reducing back-and-forth delays and improving approval rates.

Formulary Placement Impact

As a Tier 5 specialty drug, Cometriq requires:

  • Prior authorization approval
  • 30-day supply limits
  • Specialty pharmacy dispensing for Part D
  • Higher copays or coinsurance (typically 25-33% of drug cost)

Avoid These 5 Preventable Mistakes

1. Wrong Formulation Prescribed

The mistake: Prescribing Cabometyx tablets instead of Cometriq capsules for medullary thyroid cancer. The fix: Ensure your oncologist specifies "Cometriq (cabozantinib) capsules" and includes the correct NDC numbers on the prior authorization form.

2. Incomplete Medical History

The mistake: Submitting PA without documenting prior treatments or surgical consultation. The fix: Include complete treatment timeline, surgical evaluation notes, and reasons why curative surgery isn't feasible.

3. Missing Progression Documentation

The mistake: Requesting approval without recent imaging showing disease progression. The fix: Submit imaging reports from the past 3-6 months demonstrating metastatic or progressive disease.

4. Generic ICD-10 Coding

The mistake: Using general thyroid cancer codes instead of specific medullary thyroid carcinoma. The fix: Use ICD-10 code C73 specifically for thyroid carcinoma, with additional codes for metastatic sites if applicable.

5. Delayed Appeal Filing

The mistake: Missing Ohio's 180-day deadline for external review requests. The fix: File internal appeals immediately after denial and track all deadlines carefully.

Quick Action Plan: 3 Steps to Take Today

Step 1: Verify Your Coverage Details

Call Humana Customer Service at 1-800-281-6918 with your member ID ready. Ask specifically:

  • Is Cometriq on my plan's formulary?
  • What tier is it classified as?
  • Do I need to use a specialty pharmacy?
  • What's the prior authorization process?

Step 2: Gather Required Documentation

Work with your oncologist's office to compile:

  • Complete medical records for your thyroid cancer diagnosis
  • Pathology reports confirming medullary thyroid carcinoma
  • Recent imaging studies showing disease progression
  • Documentation of surgical consultation and non-resectability
  • List of all prior treatments and their outcomes

Step 3: Submit Complete Prior Authorization

Have your oncologist submit the PA through Humana's provider portal or fax to 877-486-2621. Ensure the submission includes all required clinical documentation and a detailed medical necessity letter explaining why Cometriq is appropriate for your specific case.

Ohio-Specific Appeals Process

If Humana denies your initial request, Ohio residents have specific rights and timelines:

Internal Appeals with Humana

  • Timeline: 65 days from denial to file
  • Standard review: 30 days for decision
  • Expedited review: 72 hours for urgent cases
  • Required: Must exhaust internal appeals before external review

Ohio External Review

  • Eligibility: Available after completing internal appeals
  • Timeline: 180 days from final internal denial to request
  • Process: File through Ohio Department of Insurance
  • Contact: Call 1-800-686-1526 or email [email protected]
  • Decision timeline: 30 days standard, 72 hours expedited

The Ohio Department of Insurance assigns cases to Independent Review Organizations (IROs) with medical experts who review your case independently. Their decisions are binding on Humana.

FAQ

Q: How long does Humana prior authorization take for Cometriq in Ohio? A: Standard review takes up to 30 days for Medicare Advantage plans, 7 days for Part D plans. Expedited reviews are completed within 72 hours if your situation is urgent.

Q: What if Cometriq isn't on my Humana formulary? A: Request a formulary exception by providing strong medical necessity documentation showing why covered alternatives aren't appropriate for your specific case.

Q: Can I get Cometriq from any pharmacy with Humana coverage? A: For Part D coverage, you must use Humana's specialty pharmacy network. Retail pharmacies cannot fill the prescription without prior authorization approval.

Q: Does step therapy apply if I've tried other treatments outside Ohio? A: Yes, prior treatment history from other states counts toward step therapy requirements. Provide complete documentation of all treatments attempted and their outcomes.

Q: What happens if I miss the 180-day deadline for Ohio external review? A: You lose the right to external review through Ohio's process. However, you may still have other options like filing complaints with regulators or pursuing legal remedies.

Q: How much will Cometriq cost with Humana coverage? A: As a Tier 5 specialty drug, expect to pay 25-33% coinsurance. For a $18,938 supply, this could mean $4,700-$6,250 out-of-pocket. Manufacturer copay assistance may help reduce costs.

Resources

Official Forms and Contacts

Clinical Resources

Patient Assistance

  • Counterforce Health - Insurance appeal assistance and prior authorization support
  • UHCAN Ohio (Universal Health Care Action Network) - Consumer advocacy and assistance

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with your insurance plan and consult with your healthcare provider about your specific medical situation. For official Ohio insurance regulations and appeal procedures, contact the Ohio Department of Insurance directly.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.