By Counterforce Health Team in Tecentriq (atezolizumab) —

Blue Cross Blue Shield California Tecentriq Coverage: Medical Necessity Requirements and Appeal Process

Answer Box: Getting Tecentriq Covered by Blue Cross Blue Shield California

Tecentriq (atezolizumab) requires prior authorization from Blue Cross Blue Shield California and is covered as a Tier 4 specialty drug for FDA-approved cancer indications. The fastest path to approval: 1) Confirm your diagnosis meets FDA-approved uses, 2) Submit a complete prior authorization request with biomarker testing (PD-L1 when required), and 3) Document any failed prior therapies. If denied, California's Independent Medical Review (IMR) through DMHC offers a 50-60% success rate for cancer drug appeals. Start today: Call Blue Shield's provider services at the number on your insurance card to request the current PA form.

Table of Contents

Policy Overview: How Blue Cross Blue Shield California Covers Tecentriq

Blue Shield of California lists Tecentriq (atezolizumab) on its Tier 4 Specialty formulary as of 2024, requiring prior authorization for all members. Coverage applies to both HMO and PPO plans, though specific requirements may vary by product type.

Coverage at a Glance

Requirement What It Means Source
Prior Authorization Required before first infusion Blue Shield CA Provider Portal
Formulary Tier Tier 4 (Specialty) - higher copays apply Blue Shield CA Drug Formulary
FDA Indication Must match approved cancer uses FDA Prescribing Information
Site of Care Network infusion centers only Blue Shield CA Medical Policy
Appeal Deadline 180 days from denial (commercial plans) California Insurance Code

The drug costs approximately $8,113-$11,589 per vial at wholesale, making it one of the higher-cost specialty oncology medications subject to strict utilization management.

FDA Indication Requirements

Tecentriq is FDA-approved for multiple cancer types, but coverage is strictly limited to these labeled indications:

  • Non-small cell lung cancer (NSCLC) - adjuvant treatment after surgery and chemotherapy
  • Extensive-stage small cell lung cancer - in combination with carboplatin and etoposide
  • Hepatocellular carcinoma - with bevacizumab for previously untreated disease
  • Melanoma - in combination with cobimetinib and vemurafenib for BRAF-mutated tumors
  • Alveolar soft part sarcoma - for unresectable or metastatic disease
Note: Some previous indications for urothelial and breast cancers were withdrawn by the FDA. Always verify current approved uses in the FDA prescribing information.

Off-Label Use Considerations

Blue Shield California generally does not cover off-label uses of Tecentriq unless supported by major treatment guidelines like NCCN. If your oncologist believes off-label use is medically necessary, prepare for a more complex appeal process requiring extensive clinical evidence.

Step Therapy and Medical Exceptions

Blue Shield California may require patients to try and fail other treatments before approving Tecentriq, depending on the cancer type and line of therapy.

Common Step Therapy Requirements

  • First-line NSCLC: May require trial of pembrolizumab (Keytruda) first
  • Hepatocellular carcinoma: Often requires documentation of Child-Pugh score and liver function
  • Second-line treatments: Must document progression on or intolerance to standard chemotherapy

Medical Exception Pathways

You can bypass step therapy if you have:

  • Documented contraindications to preferred agents (allergies, organ dysfunction)
  • Previous treatment failures outside the current insurance plan
  • Clinical factors making preferred drugs inappropriate (drug interactions, comorbidities)

Document these exceptions thoroughly in your prior authorization request with specific medical rationale and supporting clinical notes.

Required Diagnostics and Biomarker Testing

Certain Tecentriq indications require specific biomarker testing before approval.

PD-L1 Testing Requirements

For first-line urothelial carcinoma in cisplatin-ineligible patients:

  • Required test: Ventana PD-L1 (SP142) Assay
  • Positive threshold: ≥5% tumor-infiltrating immune cells
  • Exception: No PD-L1 testing needed if patient is ineligible for ANY platinum-based chemotherapy

Other Required Testing

  • Hepatocellular carcinoma: Recent imaging showing liver lesions, Child-Pugh classification
  • NSCLC: Molecular testing for EGFR, ALK, and other actionable mutations
  • Melanoma combinations: BRAF mutation testing required
Tip: Order biomarker testing early in the treatment planning process. Results can take 1-2 weeks, and missing test results are a common cause of PA delays.

Site of Care and Specialty Pharmacy Requirements

Tecentriq must be administered in qualified healthcare facilities - never at home or through retail pharmacies.

Approved Administration Sites

  • Hospital outpatient infusion centers
  • Freestanding infusion clinics (network-contracted)
  • Oncology practice infusion suites

Specialty Pharmacy Distribution

Blue Shield California typically requires Tecentriq to be:

  • Sourced through contracted specialty pharmacies for delivery to the infusion site
  • Billed under the medical benefit (not pharmacy benefit)
  • Administered only by qualified oncology professionals

Verify your infusion center is in-network and can handle specialty drug procurement before scheduling treatment.

Medical Necessity Documentation

A strong medical necessity letter is crucial for Tecentriq approval. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing plan policies and crafting point-by-point rebuttals that align with each insurer's specific requirements.

Essential Documentation Elements

Patient Information:

  • Full name, date of birth, insurance ID
  • Primary diagnosis with ICD-10 code
  • Cancer stage and histology

Clinical History:

  • Prior treatments attempted and outcomes
  • Dates of progression or treatment failure
  • Reasons for discontinuation (toxicity, intolerance)

Treatment Rationale:

  • Why Tecentriq is medically necessary for this patient
  • Supporting evidence from FDA labeling or NCCN guidelines
  • Planned dosing schedule and duration

Sample Medical Necessity Statement

"Mr. [Name] has metastatic non-small cell lung cancer (C78.00) with PD-L1 expression of 15% by SP142 assay. He progressed on carboplatin/pemetrexed after 4 cycles and developed grade 3 neuropathy precluding further platinum therapy. Per NCCN guidelines and FDA labeling, atezolizumab 1200mg IV every 3 weeks represents standard-of-care immunotherapy for his clinical scenario. Alternative checkpoint inhibitors are contraindicated due to his history of autoimmune thyroiditis."

Appeals Process in California

If Blue Shield California denies your Tecentriq request, California offers robust appeal rights through multiple levels.

Step-by-Step Appeals Process

1. Internal Appeal (Grievance)

  • Timeline: Must file within 180 days of denial
  • Process: Submit appeal form with additional clinical documentation
  • Decision time: 30 days for standard, 72 hours for urgent

2. Independent Medical Review (IMR)

  • When to use: After internal appeal denial or if plan doesn't respond in 30 days
  • Success rate: 50-60% for cancer drug appeals
  • Cost: Free to patients
  • Timeline: 45 days standard, 7 days expedited

3. Contact Information

From our advocates: "We've seen Tecentriq denials overturned at IMR when physicians provided clear documentation of failed prior therapies and cited specific NCCN guideline recommendations. The key is submitting comprehensive clinical evidence that directly addresses the plan's stated denial reasons."

Required Appeal Documents

  • Original denial letter
  • Complete medical records
  • Physician statement of medical necessity
  • Relevant lab results and imaging
  • Treatment timeline and prior therapy documentation

Common Denial Reasons and Solutions

Denial Reason How to Overturn
"Not FDA approved for this indication" Provide current FDA prescribing information showing approved use
"Experimental/investigational" Submit NCCN guidelines or peer-reviewed studies supporting use
"Step therapy not completed" Document contraindications or failures of preferred agents
"Missing PD-L1 testing" Order Ventana SP142 assay and submit results
"Site of care not appropriate" Confirm network infusion center and resubmit

The platform offered by Counterforce Health can help identify the specific denial basis and draft targeted rebuttals that address each plan's unique coverage criteria.

Cost Assistance Options

Even with insurance coverage, Tecentriq can involve significant out-of-pocket costs for California patients.

Financial Assistance Programs

  • Genentech Patient Foundation: Need-based grants for uninsured/underinsured patients
  • Co-pay assistance: Up to $25,000 annually for commercially insured patients
  • State pharmaceutical assistance: California has various programs for low-income residents

Eligibility Requirements

Most manufacturer programs require:

  • Commercial insurance (not Medicare/Medicaid)
  • Household income limits (varies by program)
  • US residency and legal status

Contact Genentech Access Solutions at 1-855-692-6729 for current program details and applications.

Frequently Asked Questions

How long does Blue Shield California prior authorization take? Standard PA decisions are made within 5 business days. Urgent requests (when delay could jeopardize health) are decided within 72 hours.

What if Tecentriq isn't on my formulary? You can request a formulary exception with medical necessity documentation. If denied, the California IMR process can review non-formulary denials.

Can I get expedited appeals for urgent cancer treatment? Yes. California law requires expedited review (within 72 hours) when standard timeframes could seriously jeopardize your health.

Does step therapy apply if I failed treatments with a previous insurer? Provide documentation of prior treatment failures to your new plan. Most insurers will accept documented failures from other plans.

What happens if my appeal is denied at all levels? After exhausting internal and external appeals, you may have legal options. Consider consulting with a healthcare attorney specializing in insurance coverage disputes.

Are there different requirements for Medicare Advantage plans? Yes. Blue Shield Medicare Advantage plans may have different PA criteria and appeal processes. Check your specific plan documents.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific Blue Shield of California plan and consult with your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting with organizations like Counterforce Health that specialize in helping patients navigate complex coverage determinations.

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