By Counterforce Health Team in Cometriq (cabozantinib) —

The Complete Guide to Getting Cometriq (Cabozantinib) Covered by Humana in Pennsylvania: Forms, Appeals, and Success Strategies

Answer Box: Getting Cometriq Covered by Humana in Pennsylvania

Cometriq (cabozantinib) requires prior authorization from Humana Medicare Advantage plans for medullary thyroid cancer treatment in Pennsylvania. Your fastest path to approval: 1) Have your oncologist submit a complete prior authorization request with diagnosis code C73 (thyroid cancer), prior treatment history, and medical necessity letter through Humana's provider portal. 2) Use CenterWell Specialty Pharmacy as your preferred in-network vendor. 3) If denied, you have 65 days to appeal and can access Pennsylvania's new external review program with a 50% overturn rate. Start today by calling Humana at 1-800-281-6918 to confirm your plan's specific requirements.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Common Denial Reasons & How to Fix Them
  10. Appeals Process in Pennsylvania
  11. Quick Reference Checklist
  12. FAQ

Who Should Use This Guide

This guide is for Pennsylvania patients with medullary thyroid carcinoma (MTC) whose doctors have prescribed Cometriq (cabozantinib) and who have Humana Medicare Advantage or Part D coverage. You'll also benefit if you've already received a denial and need to file an appeal.

Expected outcome: Following this guide increases your chances of first-time approval and helps you navigate Pennsylvania's appeals process effectively if needed. With proper documentation, most medically appropriate requests for FDA-approved indications are ultimately approved.

Member & Plan Basics

Coverage Requirements

  • Active Humana enrollment in Pennsylvania (Medicare Advantage or Part D)
  • Specialty drug coverage on your plan (verify through Humana's formulary search)
  • Prior authorization required for all Cometriq prescriptions

Plan Types That Cover Cometriq

  • Humana Medicare Advantage with prescription drug coverage (MAPD)
  • Humana standalone Part D plans
  • Some Humana commercial plans (check your specific formulary)
Note: Cometriq is typically covered under Medicare Part D (pharmacy benefit), not Part B (medical benefit), since it's an oral medication.

Clinical Criteria for Approval

Humana requires these clinical criteria to be met for Cometriq approval:

Primary Requirements

Requirement Details Documentation Needed
Diagnosis Progressive, metastatic medullary thyroid carcinoma Pathology report, imaging showing progression
Age 18 years or older Date of birth verification
Prescriber Oncologist or prescribed in consultation with oncologist Provider credentials, referral if applicable
Disease Status Not amenable to curative surgery Surgical consultation notes or oncologist statement

FDA-Approved Indication

Cometriq is specifically approved for progressive, metastatic medullary thyroid carcinoma in adults. Off-label uses may face additional scrutiny and require more extensive documentation.

Dosing Requirements

  • Maximum dose: 140 mg daily (180 mg with strong CYP3A4 inducers)
  • Must follow FDA labeling guidelines
  • No contraindications present (recent hemorrhage, uncontrolled hypertension)

Coding Requirements

Essential Codes for Billing

Code Type Code Description
ICD-10 C73 Malignant neoplasm of thyroid gland
NDC (20mg) 42388-001-20 Cometriq 20mg capsules
NDC (80mg) 42388-002-80 Cometriq 80mg capsules
HCPCS C9399 or J3490 Unclassified drugs (if hospital outpatient)
Critical: Use Cometriq capsule NDCs only. Using Cabometyx (tablet) NDCs is a common error that causes denials.

Documentation Packet

Medical Necessity Letter Components

Your oncologist's letter should include:

  1. Patient identification (name, DOB, insurance ID)
  2. Diagnosis statement with ICD-10 code C73
  3. Disease progression evidence (imaging, clinical notes)
  4. FDA indication confirmation ("Cometriq is FDA-approved for progressive, metastatic MTC")
  5. Prior treatments and outcomes (if applicable)
  6. Contraindication screening ("No recent hemorrhage or uncontrolled hypertension")
  7. Dosing plan (specific mg daily)
  8. Prescriber credentials and contact information

Required Attachments

  • Recent clinic notes (within 30-60 days)
  • Pathology report confirming MTC diagnosis
  • Recent imaging showing metastatic/progressive disease
  • Prior treatment records (if step therapy applies)
  • Completed prior authorization form

Submission Process

Step-by-Step Submission

  1. Obtain the correct PA form from Humana's prior authorization page
  2. Complete all required fields (incomplete forms are commonly rejected)
  3. Submit via provider portal or fax to the number on the form
  4. Include all supporting documents in one submission
  5. Request confirmation of receipt
  6. Follow up if no response within 5 business days

Submission Methods

  • Online: Humana Provider Portal (preferred)
  • Fax: Use the fax number specific to your form
  • Phone: 1-800-281-6918 for assistance

Specialty Pharmacy Requirements

Preferred Network

CenterWell Specialty Pharmacy is Humana's preferred specialty pharmacy in Pennsylvania for 2024.

Contact Information:

  • Phone: 1-800-486-2668 (TTY: 711)
  • Fax for prescriptions: 1-877-405-7940

Transfer Process

  1. Ask your prescriber to send the prescription directly to CenterWell
  2. CenterWell handles prior authorization coordination
  3. They'll contact you about shipping and financial assistance options
  4. Medication ships directly to your address
Tip: Using CenterWell typically results in lower out-of-pocket costs and streamlined prior authorization processing.

After Submission: What to Expect

Timeline for Decisions

  • Standard review: Up to 30 days for Medicare Advantage
  • Expedited review: 72 hours if urgent (life-threatening situation)
  • Part D decisions: 7 days standard, 72 hours expedited

Status Tracking

  • Call Humana Customer Service: 1-800-281-6918
  • Check online through your member portal
  • Your prescriber can check through the provider portal

What to Record

  • Confirmation number of submission
  • Date submitted
  • Representative name (if submitted by phone)
  • Expected decision date

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
Wrong formulation Emphasize Cometriq capsules vs. Cabometyx tablets Prescription specifying "Cometriq capsules"
Missing oncologist involvement Add oncologist consultation or referral Oncologist letter or consultation notes
Incomplete diagnosis Specify "medullary thyroid carcinoma" Updated pathology report, ICD-10 C73
Step therapy required Document prior treatment failures Treatment history, intolerance documentation
Not medically necessary Strengthen clinical justification Additional imaging, progression documentation

Appeals Process in Pennsylvania

Humana Internal Appeals

If your initial request is denied, you have 65 days to file an appeal with Humana.

How to Appeal:

  • Online: Humana member portal
  • Phone: 1-800-281-6918
  • Mail/Fax: Use the Appeal, Complaint or Grievance Form

Timeline: Humana must respond within 7 days (72 hours if expedited).

Pennsylvania External Review

Pennsylvania launched a new Independent External Review Program in January 2024 with impressive results.

Key Benefits:

  • 50% overturn rate in the first year
  • State-supervised process
  • Binding decisions on insurers

How It Works:

  1. Complete Humana's internal appeal first
  2. Request external review within 4 months of final denial
  3. Submit through Pennsylvania Insurance Department online portal
  4. Independent physicians review your case
  5. Decision within 45 days (72 hours if expedited)

Contact Information:

From our advocates: "We've seen several Pennsylvania patients successfully overturn Humana denials for specialty cancer drugs through the new external review process. The key is submitting comprehensive clinical documentation that clearly shows the medication is medically necessary and appropriate for the patient's specific condition."

When to Get Help

Contact the Pennsylvania Health Law Project for free assistance with complex appeals, especially if you're low-income or need help navigating the process.

Quick Reference Checklist

Before You Start

  • Confirm active Humana coverage in Pennsylvania
  • Verify Cometriq is prescribed for medullary thyroid carcinoma
  • Ensure prescriber is an oncologist or has oncology consultation
  • Gather recent clinic notes and imaging

Documentation Checklist

  • Completed prior authorization form
  • Medical necessity letter from oncologist
  • Pathology report confirming MTC diagnosis
  • Recent imaging showing progression/metastases
  • Prior treatment history (if applicable)
  • Insurance card and member ID

Submission Checklist

  • All forms completely filled out
  • Correct Cometriq capsule NDCs used
  • ICD-10 code C73 included
  • Submitted to CenterWell Specialty Pharmacy
  • Confirmation number obtained
  • Follow-up scheduled

For patients and clinicians dealing with insurance coverage challenges, Counterforce Health offers a specialized platform that helps turn insurance denials into targeted, evidence-backed appeals. The system analyzes denial letters and plan policies to create point-by-point rebuttals aligned with each payer's specific requirements, potentially saving significant time in the appeals process.

FAQ

How long does Humana prior authorization take for Cometriq in Pennsylvania? Standard decisions take up to 30 days for Medicare Advantage plans, 7 days for Part D. Expedited reviews are completed within 72 hours if your health is at serious risk.

What if Cometriq is not on my Humana formulary? You can request a formulary exception through the same prior authorization process. Provide strong medical necessity documentation showing why covered alternatives aren't appropriate.

Can I get an expedited appeal if Humana denies my request? Yes, if waiting for the standard appeal timeline could seriously harm your health, you can request an expedited appeal. Your doctor must support this request with clinical documentation.

Does step therapy apply to Cometriq for medullary thyroid cancer? Step therapy requirements vary by plan. If required, document why alternative treatments failed, caused intolerable side effects, or are contraindicated for your specific situation.

What happens if I disagree with Pennsylvania's external review decision? The external review decision is binding on your insurance company. However, you may have additional options through Medicare's appeals process if your case meets minimum dollar thresholds.

How much does Cometriq cost without insurance in Pennsylvania? Cash prices can exceed $18,000 for a month's supply. Check the Cometriq manufacturer website for patient assistance programs and copay cards that may help reduce costs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about your specific medical situation and contact your insurance company directly for the most current coverage information. Coverage policies and procedures may change, so verify all details with official sources before making decisions about your care.

For complex insurance appeals and coverage challenges, Counterforce Health provides specialized tools that help patients, clinicians, and specialty pharmacies navigate the prior authorization and appeals process more effectively by creating targeted, evidence-backed submissions tailored to each payer's specific requirements.

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