By Counterforce Health Team in Cometriq (cabozantinib) —

Renewing Cometriq (Cabozantinib) Approval with Blue Cross Blue Shield in Washington: Complete Timeline and Documentation Guide

Quick Answer: Blue Cross Blue Shield Washington typically requires renewal every 6-12 months for Cometriq (cabozantinib) with documented stable disease or response via imaging (CT/MRI every 2-3 months) and biochemical markers (calcitonin/CEA). Submit renewal 2-4 weeks before expiration through your oncologist with recent scans, lab trends, and toxicity assessment. If denied, you have 180 days to appeal internally, then external review through Washington's IRO process.

Table of Contents

  1. Renewal Triggers and Timing
  2. Evidence Update Requirements
  3. Renewal Documentation Packet
  4. Timeline and Decision Windows
  5. If Coverage Lapses
  6. Annual Plan Changes
  7. Personal Progress Tracker
  8. Appeals Process
  9. FAQ

Renewal Triggers and Timing

Blue Cross Blue Shield plans in Washington typically approve Cometriq (cabozantinib) for 6-12 month periods for metastatic medullary thyroid carcinoma. Your renewal clock starts ticking based on several key triggers:

When to Start Early

  • 2-4 weeks before expiration: Submit renewal paperwork early to avoid gaps
  • New side effects: Significant toxicity requiring dose changes may trigger early review
  • Disease progression: Any signs of worsening disease on imaging or labs
  • Plan changes: January formulary updates or mid-year policy revisions
Tip: Set a calendar reminder 30 days before your current authorization expires. Most denials happen due to late submissions rather than medical necessity issues.

Signs You Should Accelerate Renewal

  • Rising calcitonin or CEA levels between scheduled monitoring
  • New symptoms suggesting progression (bone pain, breathing difficulties)
  • Upcoming travel or provider changes
  • Insurance plan transitions (job changes, Medicare eligibility)

Evidence Update Requirements

For successful Cometriq renewal, Blue Cross Blue Shield expects documented evidence that treatment continues to provide clinical benefit. Here's what your oncologist needs to compile:

Response to Therapy Documentation

Imaging Requirements:

  • Recent CT or MRI (within 8-12 weeks) showing stable disease or partial response
  • RECIST 1.1 measurements comparing current scans to baseline and prior studies
  • New lesion assessment to rule out progression

Biochemical Monitoring:

  • Calcitonin levels every 2-3 months with trend analysis
  • CEA levels measured alongside calcitonin
  • Doubling time calculations if applicable (stable or improving trends support renewal)

Adverse Events and Management

Your renewal packet must address how side effects are being managed:

Common Cometriq Side Effects Documentation Needed
Diarrhea, nausea CTCAE grading, supportive measures, dose modifications
Hypertension Blood pressure logs, antihypertensive medications
Hand-foot skin reaction Severity assessment, topical treatments, activity impact
Fatigue, weight loss Performance status (ECOG), nutritional interventions

Adherence Verification

Blue Cross Blue Shield may request:

  • Pharmacy fill records showing consistent medication pickup
  • Pill counts or specialty pharmacy compliance reports
  • Patient-reported adherence questionnaires

Renewal Documentation Packet

Your oncologist should prepare a comprehensive renewal submission including:

Must-Include Documents

  1. Updated Letter of Medical Necessity addressing:
    • Continued metastatic medullary thyroid carcinoma diagnosis (ICD-10: C73)
    • Current Cometriq dose and any modifications
    • Response assessment with specific measurements
    • Toxicity profile and management strategies
    • Plan for continued monitoring
  2. Recent Imaging Reports with radiologist interpretation and RECIST measurements
  3. Laboratory Results showing calcitonin and CEA trends over the past 6 months
  4. Treatment Timeline documenting:
    • Start date of current Cometriq course
    • Any dose reductions or interruptions
    • Concurrent medications for side effect management

Brief Letter of Medical Necessity Structure

Patient: [Name, DOB, Member ID]
Diagnosis: Metastatic medullary thyroid carcinoma (C73)
Current Treatment: Cometriq 140mg daily (or current dose)

Clinical Update:
- Most recent imaging [date]: [stable disease/partial response]
- Calcitonin trend: [specific values and dates]
- Performance status: ECOG [0-2]
- Toxicity: [grade and management]

Request: Continue Cometriq for [6-12 months] with ongoing monitoring per NCCN guidelines.

Timeline and Decision Windows

Understanding Blue Cross Blue Shield's processing timelines helps prevent coverage gaps:

Standard Renewal Timeline

Step Timeframe Action Required
Submit renewal 2-4 weeks before expiration Oncologist submits via provider portal
Initial review 3-5 business days BCBS reviews for completeness
Medical review 5-14 calendar days Clinical team evaluates medical necessity
Decision notification Within 15 calendar days total Approval/denial letter sent

Expedited Review Options

For urgent situations, request expedited review if:

  • Current supply will run out before standard decision
  • Disease progression requires immediate treatment adjustment
  • Patient experiencing severe symptoms

Expedited timeline: 24-72 hours for decision

If Coverage Lapses

Despite best planning, coverage gaps can occur. Here are your bridge options:

Temporary Coverage Solutions

Manufacturer Support:

  • Exelixis Access Services (EASE) offers a 30-day free trial for new patients and additional supply for insurance delays ≥5 days
  • Patient Assistance Program for eligible uninsured/underinsured patients
  • Contact: 1-844-900-EASE or cometriq.com/support

Emergency Supplies:

  • One-time emergency fill (7-14 days) while appeal is processed
  • Prior authorization bridge through specialty pharmacy
  • Physician samples if available (limited supply)

Escalation Steps

  1. Contact member services immediately when denial received
  2. Request peer-to-peer review between BCBS medical director and your oncologist
  3. File internal appeal within 180 days of denial
  4. Prepare for external review through Washington's IRO process if internal appeal fails

Annual Plan Changes

January brings potential changes that could affect your Cometriq coverage:

Formulary Monitoring

What to Verify Annually:

  • Tier placement: Cometriq typically remains specialty tier (Tier 4/5)
  • Prior authorization requirements: May become more or less restrictive
  • Quantity limits: Usually 30-day supplies for oral oncology drugs
  • Preferred alternatives: New drugs may be added requiring step therapy

Plan Design Shifts

  • Deductible changes: Higher deductibles increase out-of-pocket costs
  • Copay adjustments: Specialty tier copays often increase annually
  • Network changes: Verify your oncologist and specialty pharmacy remain in-network
Note: Blue Cross Blue Shield must provide 30-day notice for formulary changes affecting current medications, with transition supplies available.

Personal Progress Tracker

Use this template to log your Cometriq journey and prepare for renewals:

Treatment Timeline

  • Start date: ___________
  • Current dose: ___________
  • Last renewal date: ___________
  • Next renewal due: ___________

Response Monitoring

  • Baseline calcitonin: ___________
  • Most recent calcitonin: ___________ (Date: _______)
  • Baseline CEA: ___________
  • Most recent CEA: ___________ (Date: _______)
  • Last imaging date: ___________
  • Response assessment: ___________

Side Effects Log

  • Current grade: ___________
  • Management strategies: ___________
  • Dose modifications: ___________

Appeals Process for Washington

If your Cometriq renewal is denied, Washington state provides strong patient protections:

Internal Appeals

  • Deadline: 180 days from denial notice
  • Timeline: BCBS must decide within 30 calendar days (72 hours for urgent)
  • Submission: Member portal, mail, or fax with denial letter and supporting records

External Review

  • When to use: After internal appeal denial or if BCBS doesn't respond timely
  • Cost: Free to patient
  • Timeline: 30 days for standard review, 72 hours for urgent
  • Process: Contact Washington Office of Insurance Commissioner at 1-800-562-6900

External review success rate: Approximately 40% of insurance denials are overturned nationally, with specialist care denials reversed at nearly twice the rate of general care denials in Washington.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with your insurer's specific requirements, potentially improving your chances of approval while saving valuable time for you and your clinical team.

FAQ

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard reviews typically complete within 3-15 calendar days. Expedited reviews for urgent situations must be completed within 24-72 hours per Washington state requirements.

What if Cometriq becomes non-formulary on my plan? You can request a formulary exception with documentation that Cometriq is medically necessary and preferred alternatives are inappropriate. Your oncologist should cite specific contraindications or prior failures.

Can I request expedited appeal if my supply runs out? Yes. Washington state expanded the definition of "urgent" to include situations causing severe pain or significant potential for health deterioration, not just immediately life-threatening conditions.

Does step therapy apply if I've already been on Cometriq? Generally no. Once you've demonstrated tolerance and response to Cometriq, step therapy requirements typically don't apply to renewals unless there are significant plan changes.

What happens if I switch Blue Cross Blue Shield plans mid-year? Contact your new plan immediately to initiate prior authorization. Most plans honor existing approvals for a transition period (30-90 days) while reviewing your case.

How do I track my appeal status? Use your Blue Cross Blue Shield member portal or call the customer service number on your insurance card. For external reviews, contact the Washington Office of Insurance Commissioner.

What if my oncologist leaves the network? Request a continuity of care exception to continue seeing your current oncologist for ongoing cancer treatment. Washington state requires insurers to provide reasonable access to specialists for complex conditions.

Are there income limits for manufacturer assistance programs? The Exelixis EASE program has different eligibility criteria for different assistance types. The 30-day free trial has no income restrictions, while the patient assistance program considers financial need and insurance status.

This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. For current requirements and personalized guidance, consult your healthcare provider and contact Blue Cross Blue Shield directly. Washington residents can get additional help from the Office of Insurance Commissioner at insurance.wa.gov or 1-800-562-6900.

Sources & Further Reading

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