By Counterforce Health Team in Tecentriq (atezolizumab) —

Do You Qualify for Tecentriq (Atezolizumab) Coverage by Cigna in Pennsylvania? Decision Tree & Next Steps

Answer Box: Your Path to Tecentriq Coverage

Most Cigna members in Pennsylvania can get Tecentriq (atezolizumab) covered with proper documentation. Cigna requires prior authorization for all Tecentriq uses, with PD-L1 testing required for certain NSCLC indications. Success rate is high: 81.7% of appealed Cigna denials are overturned. Start today: Confirm your diagnosis meets Cigna's oncology policy, gather PD-L1 results (if applicable), and submit via your provider's portal or fax to (855) 840-1678.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Your Action Plan
  4. If "Possibly Eligible" - Tests & Timeline
  5. If "Not Yet" - Alternative Paths
  6. If Denied - Pennsylvania Appeal Options
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Frequently Asked Questions
  10. Sources & Further Reading

How to Use This Decision Tree

This guide helps you navigate Cigna's prior authorization process for Tecentriq (atezolizumab) in Pennsylvania. Work through each section based on your current situation—whether you're just starting the approval process or appealing a denial.

Before you begin, gather:

  • Your Cigna insurance card and member ID
  • Complete cancer diagnosis with staging
  • Lab results (especially PD-L1 testing if applicable)
  • List of previous cancer treatments and outcomes
  • Your oncologist's contact information
Note: This guide applies to commercial Cigna plans and Medicare Advantage. If you have a self-funded employer plan, some procedures may differ—check with your HR department.

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

Check if your cancer type is FDA-approved for Tecentriq:

✅ Likely Eligible:

  • Non-small cell lung cancer (NSCLC) - adjuvant or metastatic
  • Extensive-stage small cell lung cancer (ES-SCLC) in combination
  • Hepatocellular carcinoma (HCC) with bevacizumab
  • Melanoma (in combination regimens)
  • Triple-negative breast cancer
  • Urothelial carcinoma

✅ Possibly Eligible:

  • Other solid tumors with high PD-L1 expression
  • Off-label uses supported by NCCN guidelines

❌ Not Yet Eligible:

  • No confirmed cancer diagnosis
  • Cancer types without FDA approval or guideline support

Step 2: Check Required Testing

For NSCLC patients specifically:

✅ Required for adjuvant NSCLC: PD-L1 expression ≥1% on tumor cells ✅ Required for first-line metastatic NSCLC: High PD-L1 expression (≥50%) if not in combination ✅ Gene mutation testing: Must show no EGFR or ALK mutations for first-line use

For other indications: PD-L1 testing requirements vary—check Cigna's current policy.

Step 3: Prior Therapy Requirements

✅ Document previous treatments:

  • Platinum-based chemotherapy (if applicable)
  • Other immune checkpoint inhibitors tried
  • Reasons for discontinuation (progression, toxicity, contraindications)

If "Likely Eligible" - Your Action Plan

Document Checklist

Your oncologist needs to submit these items with the prior authorization:

Required Clinical Documentation:

  • ICD-10 diagnosis code with cancer stage
  • Pathology report confirming cancer type
  • PD-L1 testing results (if required for your indication)
  • Gene mutation testing (EGFR, ALK status for NSCLC)
  • Complete treatment history with dates and outcomes
  • Current performance status and prognosis
  • Planned Tecentriq dosing regimen (840mg q2w, 1200mg q3w, or 1680mg q4w)

Supporting Evidence:

  • Reference to FDA labeling or NCCN guidelines
  • Clinical rationale for Tecentriq over alternatives
  • Contraindications to preferred formulary options

Submission Path

Primary Route: Your oncologist submits through:

  • Cigna provider portal (fastest)
  • Fax: (855) 840-1678
  • Phone for urgent cases: (800) 882-4462

Expected Timeline:

  • Standard review: 5 business days
  • Expedited review: 72 hours (if medical urgency documented)

If "Possibly Eligible" - Tests & Timeline

Additional Testing to Request

If your initial eligibility is unclear, work with your oncologist to obtain:

  1. Comprehensive biomarker testing including PD-L1 expression
  2. Updated staging scans to confirm current disease status
  3. Documentation of treatment failures with specific dates and reasons

Timeline to Re-apply

  • Within 30 days: Gather missing documentation
  • Within 60 days: Resubmit with complete clinical picture
  • Track deadlines: Pennsylvania external review requires action within 4 months of final denial

If "Not Yet" - Alternative Paths

Formulary Alternatives to Discuss

If Tecentriq isn't immediately approved, consider these covered options:

  • Pembrolizumab (Keytruda) - often preferred for NSCLC
  • Nivolumab (Opdivo) - alternative PD-1 inhibitor
  • Combination regimens that may include Tecentriq

Exception Request Strategy

Non-formulary exception: If Tecentriq isn't on your plan's formulary:

  1. Document medical necessity
  2. Show contraindications to covered alternatives
  3. Request tier exception to reduce cost-sharing

Step therapy override: If step therapy is required:

  1. Document previous immunotherapy failures
  2. Show clinical urgency that doesn't allow time for step therapy
  3. Provide evidence of likely benefit from Tecentriq specifically

If Denied - Pennsylvania Appeal Options

Pennsylvania offers a robust appeals process with high success rates. In 2024, about 50% of external appeals were overturned in favor of patients.

Level 1: Internal Appeal

Timeline: File within 180 days of denial Process: Submit through Cigna member portal or mail Decision: Within 30 days for standard, 72 hours for urgent

Level 2: Peer-to-Peer Review

Who: Your oncologist speaks directly with Cigna medical director When: Available if Level 1 fails Success rate: 81.7% of Cigna appeals are at least partially overturned

Level 3: Pennsylvania External Review

New in 2024: State-run independent review program Timeline: Must file within 4 months of final internal denial Process: Submit via Pennsylvania Insurance Department portal Decision: 45 days for standard, 72 hours for urgent Success rate: ~50% of appeals overturned

From our advocates: We've seen cases where comprehensive PD-L1 documentation and clear treatment history timelines made the difference between denial and approval. The key is showing not just that you meet criteria, but why Tecentriq is specifically necessary for your situation.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Cigna provider portal Cigna PA List
PD-L1 Testing ≥1% for adjuvant NSCLC, ≥50% for first-line metastatic Pathology report Cigna Oncology Policy
Specialty Pharmacy Must use Accredo or Express Scripts Insurance card or portal Cigna Formulary
Step Therapy May require trying alternatives first Plan documents Coverage Policy
Appeals Deadline 180 days internal, 4 months external Denial letter PA External Review

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Not medically necessary" Submit NCCN guidelines reference Updated clinical notes, guidelines citation
"PD-L1 testing missing" Provide lab results Pathology report with PD-L1 percentage
"Alternative available" Document contraindications Treatment history, adverse reactions
"Off-label use" Show NCCN category 1 or 2A support Guidelines excerpt, clinical rationale
"Quantity limits exceeded" Justify dosing frequency FDA label reference, weight/BSA calculations

Frequently Asked Questions

How long does Cigna prior authorization take in Pennsylvania? Standard requests: 5 business days. Expedited requests (urgent medical need): 72 hours. Track your request through the Cigna provider portal.

What if Tecentriq is non-formulary on my plan? Request a formulary exception with clinical justification. Show why covered alternatives are inappropriate for your specific situation.

Can I request an expedited appeal? Yes, if delay would jeopardize your health. Document the medical urgency and request expedited review at each level.

Does step therapy apply if I've failed immunotherapy outside Pennsylvania? Yes, but document the previous treatments clearly. Out-of-state treatment history counts toward step therapy requirements.

What's the cost difference between tiers? Tecentriq is typically specialty tier with highest cost-sharing. Expect $100-500+ monthly copays depending on your plan.

Who can help with appeals in Pennsylvania? Contact the Pennsylvania Health Law Project for free assistance, especially if you're low-income.

At Counterforce Health, we help patients navigate complex prior authorization and appeals processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific basis for denial and draft point-by-point rebuttals aligned to the plan's own rules.

When facing a Tecentriq denial from Cigna, Counterforce Health can help identify whether the issue is PA criteria, step therapy requirements, non-formulary status, or medical necessity determinations, then provide the right evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—woven into appeals that meet Pennsylvania's procedural requirements.

Sources & Further Reading

This guide is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan documents for the most current requirements. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department's Office of Consumer Services.

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