Subject: Specialty Quantity Limit Cabometyx 1614-H P2025

Drug

CABOMETYX  (cabozantinib)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Cabometyx (cabozantinib) tablet 20mg	30 per 30 days
Cabometyx (cabozantinib) tablet 40mg	30 per 30 days
Cabometyx (cabozantinib) tablet 60mg	30 per 30 days

FDA-recommended Dosing

Recommended dose for hepatocellular carcinoma

As a single agent: 60 mg once daily.

Recommended dose for renal cell carcinoma

As a single agent

60 mg once daily.

In combination with nivolumab

40 mg once daily.

Recommended dose for differentiated thyroid cancer and neuroendocrine tumors

Adults and pediatric patients 12 years and older with bodyweight greater than or equal to 40 kg

60 mg once daily.

Pediatric patients 12 years of age and older with bodyweight less than 40 kg

40 mg once daily.

Can be dose adjusted as necessary.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Cabometyx [package insert]. Alameda, CA: Exelixis, Inc.; March 2025.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

October 12, 2025