By Counterforce Health Team in Cometriq (cabozantinib) —

The Requirements Checklist to Get Cometriq (Cabozantinib) Covered by Aetna (CVS Health) in Michigan

Answer Box: Get Cometriq Covered by Aetna CVS Health in Michigan

Cometriq (cabozantinib) requires prior authorization from Aetna CVS Health for medullary thyroid carcinoma in Michigan. Submit complete documentation including confirmed MTC diagnosis (ICD-10: C73), prior treatment history, and medical necessity justification via the Aetna provider portal or fax to 866-249-6155. Standard decisions take 72 hours; if denied, file internal appeal within 180 days, then Michigan DIFS external review within 127 days.

First step today: Gather your pathology report, imaging showing progression, and prior therapy records—these are required for approval.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. CVS Specialty Pharmacy Enrollment
  8. After Submission: Tracking Your Request
  9. Common Denial Prevention Tips
  10. Appeals Process for Michigan
  11. Printable One-Page Checklist

Who Should Use This Checklist

This comprehensive requirements checklist is designed for Michigan residents with Aetna CVS Health insurance who need Cometriq (cabozantinib) for metastatic medullary thyroid carcinoma. You'll also find this helpful if you're a healthcare provider submitting prior authorization requests or if you've received a denial and need to appeal.

Expected outcome: Following this checklist increases your approval chances significantly. Most complete submissions with proper documentation are approved within 72 hours for standard requests.

Key scenarios where this applies:

  • New Cometriq prescription for confirmed medullary thyroid cancer
  • Transfer from another specialty pharmacy to CVS Specialty
  • Appeal after initial denial
  • Annual reauthorization renewal

Member & Plan Basics

Active Coverage Verification

Before starting your prior authorization, confirm these basics:

✓ Insurance Status

  • Active Aetna CVS Health coverage
  • Member ID and group number available
  • Prescription drug benefits included (not just medical)

✓ Plan Type Considerations

  • Commercial plans: Standard PA process applies
  • Medicare Advantage: May have additional CMS requirements
  • Medicaid managed care: Different appeal timelines may apply

✓ Deductible & Authorization Requirements

  • Cometriq is a specialty tier medication requiring prior authorization
  • High deductible plans: PA approval doesn't waive deductible requirements
  • Check if quantity limits apply (typically 140mg daily maximum)

Clinical Criteria Requirements

FDA-Approved Indication

✓ Primary Indication: Metastatic medullary thyroid carcinoma (MTC)

  • Must be confirmed by pathology report
  • Disease progression documented by imaging
  • Not interchangeable with Cabometyx tablets

Step Therapy Requirements

✓ Prior Treatment Documentation

  • Document previous therapies attempted and outcomes
  • Include reasons for discontinuation (progression, intolerance, contraindications)
  • Vandetanib consideration (if applicable and not contraindicated)

✓ Contraindications to Alternatives

  • Document any medical reasons why other treatments aren't suitable
  • Include relevant lab values or imaging that support Cometriq selection

Dosing and Duration

✓ Appropriate Dosing

  • Standard dose: 140mg orally once daily
  • Document any dose adjustments needed for drug interactions
  • Include planned monitoring schedule

Coding & Billing Requirements

ICD-10 Diagnostic Codes

✓ Primary Diagnosis

  • C73 - Malignant neoplasm of thyroid gland (required)
  • Additional codes for metastatic sites if applicable (e.g., C78.00 for lung metastases)

NDC Numbers for Billing

✓ Correct Product Identification

  • Cometriq 20mg capsules: 42388-0017-01
  • Cometriq 80mg capsules: 42388-0018-01
  • Do NOT use HCPCS J-codes (will cause claim denial)

Billing Notes

✓ Important Reminders

  • Bill under pharmacy benefit, not medical
  • Use NDC numbers, not J-codes
  • Specify "Cometriq capsules" to distinguish from Cabometyx tablets

Documentation Packet Checklist

Provider Note Elements

✓ Patient Demographics

  • Full name, DOB, Aetna member ID
  • Prescriber NPI, DEA number, contact information

✓ Clinical History

  • Confirmed MTC diagnosis with pathology report
  • Disease staging (TNM or other staging system)
  • Recent imaging showing progression
  • Serum calcitonin levels post-thyroidectomy

✓ Treatment Rationale

  • Why Cometriq is medically necessary now
  • Previous therapies tried and outcomes
  • Contraindications to alternatives
  • Expected treatment goals and monitoring plan

Letter of Medical Necessity Components

A strong medical necessity letter should include:

✓ Clinical Justification

  • Reference to FDA approval for MTC
  • Current NCCN guidelines supporting use
  • Patient-specific factors requiring this therapy

✓ Safety Monitoring Plan

  • Planned assessment intervals
  • Laboratory monitoring schedule
  • Adverse event management strategy

Required Attachments

✓ Supporting Documentation

  • Pathology report confirming MTC diagnosis
  • Recent imaging reports (CT, MRI, or PET scans)
  • Laboratory results (calcitonin, CEA levels)
  • Previous treatment records and outcomes
  • Current clinical notes summarizing disease status

Submission Process

Correct Form Selection

✓ Use Current Forms

Submission Methods

✓ Electronic Submission (Preferred)

  • Availity provider portal
  • Novologix platform
  • Direct electronic prior authorization

✓ Fax Submission

  • Specialty drugs fax: 866-249-6155
  • Include cover sheet with member ID and drug name
  • Confirm receipt within 24 hours

Required Fields That Commonly Cause Rejections

✓ Critical Information

  • Complete prescriber DEA and NPI numbers
  • Exact drug name: "Cometriq" (not "cabozantinib" or "Cabometyx")
  • Specific strength and quantity requested
  • ICD-10 diagnosis code C73
  • Clear medical necessity rationale

CVS Specialty Pharmacy Enrollment

Since Aetna typically requires specialty medications through CVS Specialty Pharmacy, coordinate this process:

Enrollment Steps

✓ Complete Enrollment Forms

✓ Prescription Transfer Process

  • Notify current pharmacy of transfer 2-3 weeks before refill needed
  • Provide CVS Specialty with complete prescription information
  • Confirm delivery address and timing

✓ Coordination Timeline

  • Allow 1-2 extra days for specialty pharmacy coordination
  • Verify copay assistance programs transfer with prescription

After Submission: Tracking Your Request

Confirmation and Status Checks

✓ Initial Confirmation

  • Record confirmation number from submission
  • Note submission date and method used
  • Keep copies of all submitted documents

✓ Status Check Schedule

  • Standard requests: Check status after 48 hours
  • Urgent requests: Follow up within 24 hours
  • Contact provider relations if no update after 72 hours

✓ What to Record

  • Case reference numbers
  • Representative names and contact information
  • Decision dates and outcomes
  • Any additional information requested

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

1. Incomplete Clinical Documentation

  • Problem: Missing pathology reports or imaging
  • Fix: Submit complete diagnostic workup with initial request

2. Wrong Drug Formulation

  • Problem: Requesting Cabometyx instead of Cometriq
  • Fix: Specify "Cometriq capsules" for medullary thyroid cancer

3. Insufficient Prior Therapy Documentation

  • Problem: Not documenting previous treatment attempts
  • Fix: Include detailed history of all prior therapies and outcomes

4. Missing Medical Necessity Rationale

  • Problem: Generic request without specific justification
  • Fix: Include detailed letter explaining why Cometriq is necessary now

5. Administrative Errors

  • Problem: Incorrect member ID, missing DEA numbers
  • Fix: Double-check all administrative details before submission
From our advocates: We've seen approval rates improve dramatically when providers submit a complete package upfront rather than responding to multiple information requests. One oncology practice increased their first-pass approval rate from 60% to 95% by using a standardized checklist similar to this one.

Appeals Process for Michigan

If your initial request is denied, Michigan residents have strong appeal rights:

Internal Appeal (Aetna)

✓ Timeline: File within 180 days of denial notice ✓ Decision: Aetna must respond within 30 days (72 hours for urgent) ✓ Submission: Include original denial letter and additional supporting evidence

Michigan DIFS External Review

After internal appeal denial, you can request external review:

✓ Deadline: 127 days after final internal denial ✓ Submission: DIFS online form or call 877-999-6442 ✓ Decision Timeline: 60 days for standard, 72 hours for expedited ✓ Binding Decision: DIFS decision is final and binding on Aetna

Expedited Appeals

For urgent medical situations: ✓ Criteria: Delay would jeopardize health or function ✓ Requirement: Physician attestation of urgency ✓ Timeline: 72-hour decision for both internal and external reviews

Printable One-Page Checklist

Before You Start

  • Active Aetna CVS Health coverage confirmed
  • Member ID and group number available
  • Confirmed MTC diagnosis with pathology report
  • Recent imaging showing progression
  • Prior treatment history documented

Required Documentation

  • Completed prior authorization form
  • Letter of medical necessity
  • Pathology report (MTC diagnosis)
  • Recent imaging reports
  • Laboratory results (calcitonin, CEA)
  • Prior therapy records and outcomes
  • Prescriber DEA and NPI numbers

Submission Details

  • Drug name: "Cometriq capsules" (not Cabometyx)
  • ICD-10 code: C73
  • NDC numbers: 42388-0017-01 (20mg) or 42388-0018-01 (80mg)
  • Fax: 866-249-6155 or electronic submission
  • Confirmation number recorded

After Submission

  • Status check scheduled (48-72 hours)
  • CVS Specialty enrollment initiated
  • Appeal timeline noted (180 days internal, 127 days DIFS)

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for patients and providers. Our platform helps identify denial reasons and drafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements. For complex cases or multiple denials, Counterforce Health can streamline your appeal process with automated documentation and deadline tracking.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions are made by your health plan based on your specific policy terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with health insurance appeals in Michigan, contact the Michigan Department of Insurance and Financial Services at 877-999-6442.

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