By Counterforce Health Team in Cabometyx (cabozantinib) —

Resources to Get Cabometyx (cabozantinib) Approved with Humana in California: Forms, Portals & Appeal Guide

Answer Box: Getting Cabometyx (cabozantinib) Covered by Humana in California

Cabometyx (cabozantinib) requires prior authorization for Humana Medicare Advantage plans in California. Submit your PA request via Humana's provider portal or fax form to 877-486-2621 within 72 hours for standard decisions. If denied, you have 65 days to appeal through Humana's internal process, then escalate to California's Independent Medical Review (IMR) through the DMHC for a binding external review. Start today: Verify your formulary status and gather diagnosis codes, prior therapy records, and clinical notes supporting medical necessity.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Online Tools
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Transfer Process
  6. Support Phone Lines and Contacts
  7. California Appeals and External Review
  8. When to Update Your Resources

Start Here: Verify Your Plan and Coverage

Before submitting any forms, confirm your specific Humana plan type and Cabometyx's coverage status:

Step 1: Check Your Plan Type

  • Medicare Advantage (Part C): Most common Humana plan in California
  • Medicare Part D: Prescription drug coverage component
  • Commercial/Employer plans: Different PA requirements may apply

Step 2: Verify Cabometyx Status Search Humana's prior authorization tool for current requirements. Cabometyx (cabozantinib tablets) requires PA for most Humana plans as a high-cost oncology medication.

Note: Don't confuse Cabometyx tablets with cabozantinib capsules (Cometriq) – they have different indications and coverage criteria.

Coverage Criteria Overview Based on Humana's 2026 Enhanced PDP guidelines, Cabometyx is approved as monotherapy for specific oncology indications including:

  • Metastatic renal cell carcinoma (RCC)
  • Hepatocellular carcinoma after sorafenib progression
  • Radioactive iodine-refractory differentiated thyroid cancer
  • Metastatic castration-resistant prostate cancer with BRCA mutations

Required Forms and Documentation

Primary Prior Authorization Form

Form Name: Humana Prior Authorization Request Form Where to Get It: Humana's PA page Current Version: Verify with provider portal for 2024-2026 updates

Required Documentation Checklist

Clinical Information Needed:

  • Primary diagnosis with ICD-10 codes
  • Staging information (for cancer indications)
  • Prior therapy history and outcomes
  • Contraindications to formulary alternatives
  • Laboratory results (including BRCA mutation status if applicable)
  • Imaging reports documenting progression
  • Prescriber attestation of medical necessity

Administrative Details:

  • Patient demographics and Humana member ID
  • Prescriber NPI and contact information
  • Requested dosing and quantity
  • NDC number for specific strength

Medical Necessity Letter Template

Your oncologist should include these key elements:

  1. Patient-specific diagnosis with staging and prognosis
  2. Prior treatment failures with specific drug names, dates, and reasons for discontinuation
  3. Clinical rationale citing FDA labeling or NCCN guidelines
  4. Contraindications to step therapy alternatives
  5. Treatment goals and monitoring plan

Submission Portals and Online Tools

Provider Portal Access

Primary Submission Method: Humana Provider Portal

  • Use the PA search tool to find drug-specific requirements
  • Upload supporting documents directly
  • Track submission status in real-time
  • Receive electronic notifications of decisions

Alternative Portal: Availity (if your practice uses this clearinghouse)

Member Portal Options

MyHumana Account: Members can initiate PA requests online Phone Alternative: Call 800-555-2546 (Mon-Fri, 8am-8pm local time) for assistance

Tip: Electronic submissions through the provider portal typically process faster than fax submissions and provide automatic status updates.

Fax Numbers and Mailing Addresses

Prior Authorization Submissions

Primary Fax: 877-486-2621 Hours: 24/7 acceptance, business hours processing

Mailing Address: Humana Pharmacy Services Prior Authorization Department P.O. Box 14546 Lexington, KY 40512-4546

Appeals and Exceptions

Appeals Fax: Include "EXPEDITED" marking if urgent Mail Address: Humana Grievances and Appeals P.O. Box 14546 Lexington, KY 40512-4546

Cover Sheet Best Practices

Include these elements on your fax cover sheet:

  • "URGENT: ONCOLOGY PRIOR AUTHORIZATION"
  • Patient name and Humana member ID
  • Total number of pages
  • Prescriber contact for questions
  • Request for expedited review if applicable

Specialty Pharmacy Transfer Process

CenterWell Specialty Pharmacy

Humana's Preferred Specialty Pharmacy: CenterWell Specialty Pharmacy Transfer Phone: 1-800-486-2668 (TTY: 711) Hours: Monday–Friday, 8 a.m. to 11 p.m.; Saturday, 8 a.m. to 6:30 p.m. ET

Transfer Steps

  1. Obtain PA approval before initiating transfer
  2. Call CenterWell with your prescription information
  3. Provide current pharmacy details for prescription transfer
  4. Verify shipping address and preferred delivery schedule
  5. Set up online account using MyHumana credentials

Prescription Fax for Providers: 1-877-405-7940

From our advocates: We've seen transfers complete most smoothly when patients call CenterWell directly after PA approval rather than waiting for their current pharmacy to initiate the process. Having your Humana member ID and prescriber information ready speeds up the call significantly.

Support Phone Lines and Contacts

Member Services

General Humana Customer Service: Available via member ID card Part D Pharmacy Questions: 800-867-6601 Appeals Status: 1-866-461-7273 (Mon-Fri 8am-6pm ET)

Provider Services

Clinical Intake Team: 800-523-0023 (24/7, includes case management) Provider Relations: 1-800-626-2741 (Mon-Fri 8am-5pm CT) PA Status Inquiries: Use provider portal or call clinical intake

What to Ask When You Call

For Members:

  • "What is the current status of my Cabometyx prior authorization?"
  • "Can you expedite my request due to my cancer diagnosis?"
  • "What specific documentation is missing from my submission?"

For Providers:

  • "Can we schedule a peer-to-peer review for this denial?"
  • "What formulary alternatives does Humana prefer for this indication?"
  • "Is there a medical director available to discuss this case?"

California Appeals and External Review

Humana Internal Appeals Process

Timeline: 65 days from denial notice to submit appeal Decision Timeframe:

  • Pre-service appeals: 30 calendar days
  • Post-service appeals: 60 calendar days
  • Expedited appeals: 72 hours

Required Form: Request for Redetermination of Medicare Prescription Drug Denial

California Independent Medical Review (IMR)

If Humana upholds their denial, California residents can escalate to the state's Independent Medical Review process through the Department of Managed Health Care (DMHC).

When You Can File IMR:

  • After completing Humana's internal appeal (30-day minimum)
  • For experimental/investigational treatment denials (immediate filing allowed)
  • For "not medically necessary" determinations

How to File:

  1. Complete the DMHC IMR Application
  2. Submit online at healthhelp.ca.gov or mail to DMHC
  3. Include all denial letters and supporting medical records
  4. Request expedited review if urgent (72-hour decision)

Success Rate: Approximately 73% of IMR cases result in approval of the requested treatment

DMHC Help Center: 1-888-466-2219 (24/7) for assistance with filing

Timeline for California Appeals

Stage Standard Timeline Expedited Timeline
Humana Internal Appeal 30-60 days 72 hours
DMHC IMR 45 days 72 hours
Medicare External Review Contact Livanta: 1-877-588-1123 As applicable

When to Update Your Resources

Quarterly Updates (Every 3 Months)

  • Formulary changes: Check Humana's updated drug lists
  • PA criteria updates: Review policy changes on provider portal
  • Form versions: Ensure you're using current PA request forms

Annual Updates (January)

  • New plan year policies: Review updated coverage criteria
  • Contact information: Verify phone numbers and fax addresses
  • California regulations: Check DMHC for new appeal procedures

Key Resources to Bookmark:

Getting Additional Support

If you're struggling with the approval process, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific coverage criteria.

For complex cases involving multiple denials or urgent clinical situations, consider working with a patient advocacy organization or healthcare attorney familiar with California insurance law. The state's consumer-friendly regulations often favor patients when proper documentation supports medical necessity.

Frequently Asked Questions

How long does Humana prior authorization take for Cabometyx in California? Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests for urgent cases are decided within 24-72 hours.

What if Cabometyx is non-formulary on my Humana plan? You can request a formulary exception by demonstrating medical necessity. This requires your doctor to show that formulary alternatives are inappropriate for your specific condition.

Can I get emergency supplies while waiting for approval? Humana may provide up to a 30-day emergency supply for new members or urgent situations. Contact member services to request this coverage.

Does California's step therapy law help with Cabometyx appeals? Yes, California requires insurers to approve step therapy overrides when formulary alternatives are contraindicated or have failed. Document prior therapy failures clearly in your appeal.

What happens if both Humana and the DMHC deny my appeal? For Medicare Advantage plans, you can escalate to federal external review through Livanta (1-877-588-1123). For other plans, consider legal consultation or complaint filing with California's Department of Insurance.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently – always verify current requirements with Humana directly. For personalized assistance with your specific situation, consult with your healthcare provider or contact Humana member services.

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