By Counterforce Health Team in Cometriq (cabozantinib) —

Resources to Get Cometriq (Cabozantinib) Approved with Cigna in Virginia: Forms, Appeals & Contact Directory

Quick Start: Getting Cometriq (Cabozantinib) Covered by Cigna in Virginia

Fastest path to approval: Your oncologist must submit a prior authorization to Cigna/Express Scripts for Cometriq capsules (not Cabometyx tablets) with documented medullary thyroid carcinoma diagnosis. Submit through Cigna's provider portal or fax the PA form with clinical justification. If denied, file internal appeal within 180 days, then external review with Virginia's Bureau of Insurance using Form 216-A within 120 days of final denial. Start today: Have your doctor's office call Cigna Provider Relations at 1-800-882-4462 to begin the PA process and confirm your plan's specialty pharmacy requirements.

Table of Contents

  1. Verify Your Plan & Find the Right Policy
  2. Required Forms & Current Versions
  3. Submission Portals & Online Access
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Setup
  6. Support Phone Lines & What to Ask
  7. Virginia State Regulators & Consumer Help
  8. Update Schedule: When to Re-Check Resources

1. Verify Your Plan & Find the Right Policy

Before starting any approval process, confirm your specific Cigna plan details and locate the current coverage policy for Cometriq (cabozantinib).

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Doctor must get approval before prescribing Plan formulary or member portal Cigna PA Requirements
Specialty Pharmacy Only Must use Accredo or designated network pharmacy Member services or plan documents Express Scripts Specialty
Age Restriction Patient must be ≥18 years old Cigna coverage policy CNF-504 Cometriq Coverage Policy
Diagnosis Required Documented medullary thyroid carcinoma Medical records with pathology Cigna Medical Necessity
Formulation Specific Cometriq capsules only (not Cabometyx tablets) FDA labeling and Cigna policy Cabometyx vs Cometriq Policy
Critical Note: Cigna covers Cometriq capsules for medullary thyroid carcinoma but does NOT cover Cabometyx tablets for this indication. Using the wrong formulation will result in automatic denial.

2. Required Forms & Current Versions

Prior Authorization Forms

Primary Form: Cigna's Prescription Drug and Related Supply Authorization Request

  • Current Version: Contact your provider or call Cigna Provider Relations for the most recent form
  • Submission: Provider must complete and submit (patients cannot submit directly)
  • Required Information: Patient demographics, diagnosis with ICD-10 codes, clinical rationale, prior treatments attempted

Exception Request Forms (if needed):

  • Formulary Exception: Virginia-specific form
  • Step Therapy Override: Same form as above, different section
  • Quantity Limit Exception: Included in standard exception request

Appeal Forms

Internal Appeals: Submit written appeal letter (no specific form required)

  • Include: Member ID, denial letter copy, additional clinical documentation
  • Timeline: Must file within 180 days of denial

External Review (Virginia): Form 216-A External Review Request

  • Deadline: 120 days from final internal appeal denial
  • Cost: Free in Virginia
  • Expedited Option: Form 216-C (Physician Certification) for urgent cases

3. Submission Portals & Online Access

Provider Portals

Express Scripts Provider Portal

Cigna Provider Portal

  • Access: Through myCigna.com provider section
  • Function: Member eligibility, benefits verification, PA submission
  • Required: Provider NPI and tax ID for registration

Member Portals

myCigna Member Portal

  • URL: www.cigna.com
  • Function: Check PA status, view coverage details, download forms
  • Note: Members cannot submit PA requests directly

4. Fax Numbers & Mailing Addresses

Prior Authorization Submissions

Fax Numbers:

  • General PA Fax: Check current form for specific number (varies by plan type)
  • Expedited/Urgent: Same number, mark "URGENT" on cover sheet

Mailing Address for PA Documents:

Cigna Healthcare
Prior Authorization Department
P.O. Box 20002
Nashville, TN 37202

Appeals & Correspondence

Internal Appeals:

Cigna Healthcare
Attn: Appeals Department
P.O. Box 182223
Chattanooga, TN 37422-7223

Member Services Correspondence:

Cigna Healthcare
Attn: Customer Service
P.O. Box 20002
Nashville, TN 37202
Cover Sheet Tips: Always include member ID, provider NPI, drug name (Cometriq), and urgency level. Number pages and include total page count.

5. Specialty Pharmacy Setup

Accredo Specialty Pharmacy (Primary Network)

Onboarding Process:

  1. Verification: Confirm Accredo is your plan's designated specialty pharmacy
  2. Enrollment: Provider or patient calls Accredo at 1-800-803-2523
  3. Transfer: If switching from retail pharmacy, Accredo handles prescription transfer
  4. Delivery: Home delivery typically within 2-3 business days after approval

Required Information:

  • Insurance card (front and back)
  • Prescriber contact information
  • Preferred delivery address
  • Emergency contact details

Alternative Specialty Pharmacies

Some Cigna plans may use different specialty pharmacy networks. Verify through:

  • Member services phone number on ID card
  • Plan documents
  • Provider relations team

6. Support Phone Lines & What to Ask

Member Services

Phone: Number on your Cigna ID card (or 1-800-997-1654) Available: 24/7/365 Ask About:

  • Prior authorization status
  • Specialty pharmacy requirements
  • Appeals deadlines and process
  • Coverage determination timeline

Provider Relations

Phone: 1-800-882-4462 (1-800-88CIGNA) Available: Business hours Ask About:

  • PA submission requirements
  • Medical necessity criteria
  • Peer-to-peer review requests
  • Clinical documentation needed

Case Management

Access: Through provider relations or member services Function: Complex case coordination, expedited reviews When to Use: Multiple denials, urgent medical situations

7. Virginia State Regulators & Consumer Help

Virginia Bureau of Insurance

External Review Process:

  • Contact: Virginia State Corporation Commission Bureau of Insurance
  • Phone: 1-877-310-6560 (Consumer Services)
  • Function: Independent review of denied claims after internal appeals

Managed Care Ombudsman:

  • Same Contact: 1-877-310-6560
  • Services: Help understanding appeal rights, informal issue resolution
  • Cost: Free

Filing External Review in Virginia

Step-by-Step Process:

  1. Complete Internal Appeals: Must exhaust Cigna's internal process first
  2. Download Form 216-A: Virginia External Review Form
  3. Gather Documents: Denial letters, medical records, physician statements
  4. Submit Within 120 Days: From date of final internal denial
  5. Independent Review: Board-certified physicians review case
  6. Decision Timeline: 45 days standard, 72 hours for urgent cases
Virginia Advantage: The state provides expedited external review for cancer treatment denials without requiring full internal appeals exhaustion in some cases.

Additional Consumer Resources

Virginia Poverty Law Center

  • Services: Legal assistance for healthcare coverage issues
  • Focus: Medicaid and ACA marketplace appeals
  • Contact: Through their website for eligibility screening

8. Update Schedule: When to Re-Check Resources

Quarterly Updates (Every 3 Months)

  • Formulary Changes: Check if Cometriq remains covered
  • PA Requirements: Verify current medical necessity criteria
  • Specialty Pharmacy: Confirm network providers

Annual Updates (January/Open Enrollment)

  • Plan Documents: Review new coverage policies
  • Forms: Download current versions of all forms
  • Contact Information: Verify phone numbers and addresses
  • State Regulations: Check Virginia Bureau of Insurance updates

Immediate Updates Needed When:

  • Plan changes (job change, Medicare transition)
  • Denial received (check current appeal deadlines)
  • Moving to/from Virginia (different state regulations apply)

Clinician Corner: Medical Necessity Documentation

For healthcare providers submitting Cometriq prior authorizations, include these elements in your clinical justification:

Required Documentation:

  • Pathology-confirmed medullary thyroid carcinoma diagnosis
  • Disease staging and progression status
  • Prior treatment history and outcomes
  • Current performance status
  • Contraindications to alternative therapies

Supporting Evidence:

  • Reference FDA approval for medullary thyroid carcinoma
  • Cite relevant clinical guidelines (NCCN, ATA)
  • Include imaging or lab results showing disease progression
  • Document patient's ability to tolerate oral therapy
From our advocates: "We've seen the strongest approvals when providers include a clear timeline of disease progression and explicitly state why standard therapies are inappropriate. One successful appeal included before-and-after imaging with radiologist reports and a detailed explanation of why vandetanib wasn't suitable due to cardiac contraindications."

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Wrong formulation (Cabometyx prescribed) Resubmit with Cometriq capsules New prescription specifying capsules
Insufficient diagnosis documentation Provide pathology report Tissue diagnosis confirming MTC
Missing prior therapy information Document treatment history Clinic notes, prior medication records
Age restriction Verify patient ≥18 years Date of birth verification
Not medically necessary Clinical appeal with guidelines NCCN guidelines, FDA labeling

Frequently Asked Questions

How long does Cigna prior authorization take for Cometriq in Virginia? Standard review: 72 hours. Urgent review: 24 hours. If no response within these timeframes, the request is considered approved under regulatory requirements.

What if Cometriq is non-formulary on my Cigna plan? Submit a formulary exception request using Virginia's exception form with clinical justification.

Can I request expedited review for cancer treatment? Yes. Virginia allows expedited external review for cancer treatment denials, sometimes without exhausting internal appeals first.

Does step therapy apply if I failed treatments in another state? Medical records from any state are valid. Provide documentation of prior treatment failures regardless of where they occurred.

What's the difference between Cometriq and Cabometyx for insurance purposes? Cigna covers Cometriq capsules for medullary thyroid carcinoma but NOT Cabometyx tablets for this indication. They are not interchangeable for coverage purposes.

How do I find Virginia-specific appeal deadlines? Internal appeals: 180 days from denial. External review: 120 days from final internal denial. These are Virginia-specific timelines.

When Coverage Gets Complex: Counterforce Health

For patients and clinicians facing repeated denials or complex prior authorization requirements, specialized support can make the difference between approval and prolonged treatment delays. Counterforce Health helps transform insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific reasons for denial and craft point-by-point rebuttals aligned to each plan's own rules.

The platform pulls the right evidence for medications like Cometriq—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaves them into appeals with all required clinical facts including diagnosis codes, prior treatment failures, and treatment goals. For Virginia residents dealing with Cigna denials, this type of systematic approach can significantly improve approval rates while saving time for busy oncology practices.

Timeline: Virginia Appeals Process

Week 1: Submit internal appeal to Cigna (180-day deadline) Week 2-4: Cigna internal review (30 days for pre-service, 60 days post-service) Week 5: If denied, prepare external review documents Week 6: Submit Form 216-A to Virginia Bureau of Insurance (120-day deadline) Week 12-18: Independent review organization decision (45 days standard)

Cost Considerations & Financial Assistance

Estimated Costs:

  • Cometriq retail price: ~$18,938 for 112-capsule pack (28-day supply)
  • Cigna specialty tier: Typically 25-50% coinsurance
  • Out-of-pocket maximum applies

Financial Assistance Options:

  • Exelixis patient assistance program
  • Foundation grants for rare cancers
  • Virginia Medicaid (if eligible)
  • Hospital charity care programs

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures change frequently. Always verify current requirements with Cigna and consult with your healthcare provider for medical decisions. For specific legal questions about insurance coverage, consult with a qualified attorney familiar with Virginia insurance law.

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