By Counterforce Health Team in Tecentriq (atezolizumab) —

Do You Qualify for Tecentriq Coverage by Blue Cross Blue Shield in Washington? Decision Tree & Next Steps

Answer Box: Getting Tecentriq Covered by Blue Cross Blue Shield in Washington

Yes, Blue Cross Blue Shield plans in Washington cover Tecentriq (atezolizumab) for FDA-approved indications, but prior authorization is required. Most approvals happen within 72 hours when you submit complete documentation. Your first step: Have your oncologist gather your diagnosis, PD-L1 test results (if applicable), and prior therapy records, then submit the PA request through your plan's provider portal or Availity system. If denied, Washington's external review process through the Office of the Insurance Commissioner gives you a second chance with binding decisions typically within 15 days.

Table of Contents

How to Use This Guide

This guide helps patients and clinicians navigate Tecentriq coverage with Blue Cross Blue Shield plans in Washington, including Premera Blue Cross and Regence BlueShield. Each section provides specific action steps based on where you are in the coverage process.

Before you start, gather these documents:

  • Insurance card with member ID
  • Complete diagnosis and staging information
  • Lab results (PD-L1 testing, genomic profiling)
  • Records of previous cancer treatments
  • Current oncologist's contact information

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis Matches FDA-Approved Uses

Tecentriq is covered for these specific conditions:

Condition Requirements PD-L1 Testing Needed?
NSCLC (Adjuvant) Stage II-IIIA, post-surgery + chemo Yes (≥1% expression)
NSCLC (Metastatic, 1st-line) No EGFR/ALK mutations Yes (≥50% TC or ≥10% IC)
NSCLC (Metastatic, combo) With bevacizumab + chemo No
SCLC (Extensive-stage) With carboplatin + etoposide No
Hepatocellular Carcinoma Unresectable/metastatic, with bevacizumab No
Alveolar Soft Part Sarcoma Unresectable/metastatic, age ≥2 No

Source: FDA prescribing information

Step 2: Check Your Blue Cross Blue Shield Plan Type

Washington has two main Blue Cross Blue Shield carriers:

  • Premera Blue Cross (including Medicare Advantage plans)
  • Regence BlueShield (including Uniform Medical Plan for state employees)

Both require prior authorization for Tecentriq, but submission processes may vary. Check your insurance card for the specific plan name.

Step 3: Verify Required Testing is Complete

For NSCLC patients: Ensure you have:

  • PD-L1 testing results using an FDA-approved assay
  • EGFR and ALK mutation testing (for metastatic disease)
  • Staging scans confirming disease extent

If You're Likely Eligible

Document Checklist for Prior Authorization

Your oncologist will need to submit these items:

Clinical Documentation:

  • ✅ Pathology report confirming diagnosis
  • ✅ Staging information (TNM classification)
  • ✅ Performance status assessment
  • ✅ PD-L1 test results (where required)
  • ✅ EGFR/ALK testing results (for NSCLC)
  • ✅ Documentation of prior treatments and responses

Administrative Items:

  • ✅ Completed prior authorization form
  • ✅ Prescriber attestation of medical necessity
  • ✅ Treatment plan with dosing schedule
  • ✅ Site of administration details

Submission Path

For Regence BlueShield plans: Submit through the Availity provider portal or fax to the number listed on your plan's PA form.

For Premera Blue Cross plans: Use Premera's provider portal or submit via the contact methods in their pharmacy prior authorization guide.

Expected timeline: 72 hours for standard requests, 24 hours for expedited cases where delay could harm your health.

Tip: Ask your oncologist's office to mark urgent cases as "expedited" on the PA form if treatment delays could worsen your prognosis.

If You're Possibly Eligible

Tests to Request

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

  1. Complete biomarker testing if not already done
  2. Document treatment failures from previous therapies
  3. Obtain updated staging scans if your last imaging is over 8 weeks old
  4. Review comorbidities that might affect alternative treatments

What to Track While Waiting

  • PA submission date (to monitor processing times)
  • Reference number from your insurer
  • Contact information for the reviewing medical director
  • Backup treatment options in case of denial

Timeline to Re-apply

If additional testing is needed, plan for:

  • 1-2 weeks for PD-L1 or genomic testing results
  • 3-5 business days for PA resubmission after receiving results
  • 72 hours for standard PA decision

If You're Not Yet Eligible

Alternatives to Discuss with Your Oncologist

If Tecentriq isn't covered for your specific situation:

Clinical alternatives:

  • Other PD-1/PD-L1 inhibitors (pembrolizumab, nivolumab)
  • Combination chemotherapy regimens
  • Targeted therapies based on tumor genetics

Coverage strategies:

  • Step therapy completion: Try formulary alternatives first
  • Formulary exception request: Submit detailed medical necessity letter
  • Off-label use justification: Provide peer-reviewed evidence

Preparing for Exception Requests

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Their platform identifies the specific denial basis and drafts point-by-point rebuttals aligned to each plan's rules.

Work with your oncologist to document:

  • Why formulary alternatives won't work (contraindications, prior failures)
  • Clinical evidence supporting Tecentriq for your specific case
  • Treatment urgency and potential consequences of delay

If You've Been Denied

Washington Appeals Process

Washington provides multiple levels of appeal with strong consumer protections:

Appeal Level Timeline How to Submit Decision Time
Internal Appeal (Level 1) 180 days from denial Through your plan 30 days
Internal Appeal (Level 2) 60 days from Level 1 Through your plan 30 days
External Review (IRO) 180 days from final denial OIC process 15 days

When to Request Expedited Appeals

Request expedited review if:

  • Your cancer is progressing rapidly
  • Delay could worsen your prognosis
  • You're between treatment cycles

Expedited timeline: 72 hours for external review decisions.

External Review Process in Washington

After exhausting internal appeals, you can request an Independent Review Organization (IRO) through the Washington Office of the Insurance Commissioner:

  1. Submit request through your health plan
  2. OIC assigns IRO with relevant medical expertise
  3. Submit additional evidence within 5 business days
  4. IRO makes binding decision within 15 days
Note: IRO decisions are binding on your insurance company. If they overturn the denial, your plan must provide coverage.

Coverage Decision Flowchart

Start: Do you have an FDA-approved indication?
├── Yes → Is required testing complete?
│   ├── Yes → Submit PA with complete documentation
│   │   ├── Approved → Begin treatment
│   │   └── Denied → File internal appeal
│   │       └── Still denied → External review (IRO)
│   └── No → Complete testing, then resubmit
└── No → Discuss alternatives or exception request

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing PD-L1 testing Submit FDA-approved test results
Off-label use Provide peer-reviewed evidence and medical necessity letter
Step therapy required Document failures/contraindications to formulary alternatives
Site of care restriction Justify medical necessity for specific infusion center

Resources and Next Steps

Key Contacts for Washington Patients

  • Premera Blue Cross: Member services at number on your ID card
  • Regence BlueShield: Provider relations for PA questions
  • Washington OIC Consumer Advocacy: 1-800-562-6900 for appeal help
  • Genentech Access Solutions: Patient support program

Financial Assistance Options

  • Genentech copay program: May reduce out-of-pocket costs
  • Foundation grants: Organizations like CancerCare offer assistance
  • Washington state programs: Apple Health (Medicaid) for eligible patients
From our advocates: "We've seen many Washington patients successfully overturn Tecentriq denials by submitting comprehensive PD-L1 testing documentation and clear medical necessity letters. The key is ensuring your oncologist addresses each specific denial reason in the appeal."

Verifying Current Coverage Criteria

Always check the most recent policy documents:

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and clinical situation. Always consult with your healthcare provider and insurance plan for the most current requirements and personalized guidance. For specialized help with appeals and prior authorization, Counterforce Health provides expert assistance in navigating insurance coverage challenges.

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