CurrentCignaPolicy N/A

Drug Quantity Management Policy - Cabometyx (cabozantinib) — Per Rx

Defines permitted per‑prescription quantity limits and medically necessary exceptions for Cabometyx (cabozantinib tablets) for Cigna-administered health benefit plans. Applies to pharmacy dispensing (retail and home delivery) for covered members of Cigna plans.

Policy Summary

PayerCigna

PolicyDrug Quantity Management Policy - Cabometyx (cabozantinib) — Per Rx

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateNov 5, 2025

Key ActionApprove quantities per dispensing up to the stated limits or the documented CYP3A4 inducer exception; approvals are provided for one year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Retail max per Rx

90Home delivery max per Rx

180Home delivery override (40 mg)

60Retail override (40 mg)

Coverage Criteria

Drug Quantity Limit Criteria

Covered when the per‑prescription quantity does not exceed the specified maximums or an approved exception applies:

Default quantity limits: For Cabometyx tablets (20 mg, 40 mg, 60 mg): Retail maximum quantity per prescription = 30 tablets; Home delivery maximum quantity per prescription = 90 tablets.Retail = 30 tablets; Home delivery = 90 tablets

All approvals are provided for 1 year in duration.

Exception for Cabometyx 40 mg with strong CYP3A4 inducer: If the patient is taking a strong cytochrome P450 (CYP)3A4 inducer, allow override for Cabometyx 40 mg: Retail = 60 tablets per dispensing; Home delivery = 180 tablets per dispensing.concomitant strong CYP3A4 inducer use

Strong CYP3A4 inducers include but are not limited to rifampicin, carbamazepine, phenobarbital, phenytoin, rifabutin, rifapentine, and St. John's Wort.

Policy Summary

PayerCigna

PolicyDrug Quantity Management Policy - Cabometyx (cabozantinib) — Per Rx

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateNov 5, 2025

Key ActionApprove quantities per dispensing up to the stated limits or the documented CYP3A4 inducer exception; approvals are provided for one year when criteria are met.

SourceLink

On This Page

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Per‑Prescription Quantity Limits

Cabometyx 20 mg tablets — per‑prescription max quantity

Per‑prescription maximum (retail)30 tablets per Rx

Per‑prescription maximum (home delivery)90 tablets per Rx

Override policyNo overrides recommended for 20 mg strength; exceptions other than listed CYP3A4 inducer exception are not medically necessary

Cabometyx 40 mg tablets — per‑prescription max quantity

Per‑prescription maximum (retail)30 tablets per Rx

Per‑prescription maximum (home delivery)90 tablets per Rx

Exception for concomitant strong CYP3A4 inducerWhen patient is taking a strong CYP3A4 inducer, retail = 60 tablets per dispensing and home delivery = 180 tablets per dispensing

Cabometyx 60 mg tablets — per‑prescription max quantity

Per‑prescription maximum (retail)30 tablets per Rx

Per‑prescription maximum (home delivery)90 tablets per Rx

Override policyNo overrides recommended for 60 mg strength; exceptions other than listed CYP3A4 inducer exception are not medically necessary

Provider Actions and Approval

Note

Approval duration and review

Approvals under the Drug Quantity Management program are provided for one year when criteria or exceptions are met. Requests that do not meet the Drug Quantity Management rule at the point of service will be reviewed against the coverage criteria; if criteria are not met, the request will be considered not medically necessary.

All approvals granted under this Drug Quantity Management policy are valid for 1 year from the date of approval.
If the quantity requested exceeds the listed Drug Quantity Limits and the documented exception criteria are not met, the request will be considered not medically necessary.
Coverage determinations follow the applicable benefit plan and medical necessity review; providers should supply documentation consistent with the plan's requirements.

Prior Authorization

Provider reminder

Provider-facing highlight: ensure quantity requested aligns with the Drug Quantity Limits for Cabometyx by strength and dispensing channel (Retail: 30 tablets per Rx; Home Delivery: 90 tablets per Rx). If requesting an exception, include supporting clinical documentation.

Documentation Required

Coverage determination documentation

Documentation to support coverage must be consistent with the member's applicable benefit plan and medical necessity review. Include clinical justification for any exception to the specified Drug Quantity Limits (e.g., dosing schedule, weight-based dosing, multiple strengths, or clinical rationale).

Provide diagnosis, prior treatments, and specific clinical rationale for exceeding quantity limits.
Attach relevant clinical notes, weight or lab data if dosing is weight-based, and any prescriber titration schedule.
Reference applicable benefit plan language where relevant.

Denial Risk

Quantity limit exceedance

Requests exceeding the documented Drug Quantity Limits without meeting the listed medically necessary exception will be considered not medically necessary and denied.

Retail maximum per Rx: 30 tablets; Home Delivery maximum per Rx: 90 tablets (all available strengths).
Exceptions must meet the specific medically necessary criteria to be approved; otherwise, denial as not medically necessary will occur.

OpenPayer

Drug Quantity Management Policy - Cabometyx (cabozantinib) — Per Rx

Coverage Criteria

Per‑Prescription Quantity Limits

Definitions

Provider Actions and Approval

Background