Get Tecentriq (Atezolizumab) Covered by Aetna CVS Health in Virginia: Complete Prior Authorization and Appeals Guide
Answer Box: Your Fast Track to Tecentriq Coverage
Getting Tecentriq (atezolizumab) covered by Aetna CVS Health in Virginia requires prior authorization with specific biomarker testing. Submit Aetna's Tecentriq precertification form with PD-L1 test results (≥1% for adjuvant NSCLC, ≥50% for first-line metastatic), negative EGFR/ALK mutation testing, and pathology reports. If denied, you have 60 days to appeal internally, then 120 days for Virginia's free external review through the State Corporation Commission. Start today: Call Aetna at 1-855-240-0535 to verify your plan's specific requirements and download the correct PA form.
Table of Contents
- Aetna's Coverage Policy Overview
- Required Testing and Documentation
- Step-by-Step Prior Authorization Process
- Common Denial Reasons and Solutions
- Internal Appeals with Aetna
- Virginia External Review Process
- Cost Assistance and Patient Support
- FAQ
Aetna's Coverage Policy Overview
Aetna CVS Health requires prior authorization for Tecentriq (atezolizumab) across all plan types in Virginia—commercial, Medicare Advantage, and Medicaid. The drug is covered under the medical benefit (not pharmacy) and billed using HCPCS code J9022.
Plan-Specific Variations:
- Commercial plans: Follow Aetna's standard clinical policy bulletin
- Medicare Advantage: Additional Medicare-specific criteria apply
- Medicaid: Virginia Medicaid managed by Aetna follows state formulary guidelines
Coverage is limited to FDA-approved indications and specific NCCN-supported uses, with strict biomarker testing requirements.
Required Testing and Documentation
Mandatory Biomarker Testing
PD-L1 Expression Testing:
- Must use FDA-approved assay on tumor tissue
- Adjuvant NSCLC: ≥1% tumor cell expression required
- First-line metastatic NSCLC: ≥50% tumor cell expression OR ≥10% tumor-infiltrating immune cells
- Include test method, date, and specific percentage in PA submission
Driver Mutation Testing:
- EGFR and ALK: Must be negative for actionable mutations
- ROS1, BRAF, NTRK: May be required depending on indication
- Submit complete molecular pathology report
Clinical Documentation Checklist
✓ Pathology report with histology confirmation
✓ Staging studies (CT chest/abdomen/pelvis, brain MRI if indicated)
✓ Performance status (ECOG 0-1 typically required)
✓ Prior treatment history with dates and outcomes
✓ Current treatment plan including dose, schedule, and duration
Clinician Corner: Include a detailed medical necessity letter addressing why Tecentriq is the optimal choice, referencing specific NCCN guidelines and explaining any contraindications to preferred alternatives.
Step-by-Step Prior Authorization Process
1. Verify Benefits and Requirements
Who: Clinic staff
Action: Call Aetna provider services at 1-800-624-0756
Timeline: Same day
Verify: Plan type, PA requirements, preferred site of care
2. Complete Required Testing
Who: Ordering physician
Action: Order PD-L1 and molecular testing if not already done
Timeline: 7-10 business days for results
Forms: Include all lab reports in PA packet
3. Submit Prior Authorization
Who: Clinic staff or oncologist
Forms: Commercial PA form or Medicare form
Submit via: Aetna provider portal or fax to number on form
Timeline: Submit at least 5-7 days before planned treatment
4. Track Decision
Timeline: Standard decisions within 15 business days, expedited within 72 hours
Follow up: Call if no response within stated timeframe
Coverage Requirements by Indication
| Indication | Line of Therapy | Required Biomarkers | Additional Requirements |
|---|---|---|---|
| Adjuvant NSCLC | Post-surgery | PD-L1 ≥1%, EGFR/ALK negative | Stage II-IIIA, completed platinum chemotherapy |
| Metastatic NSCLC | First-line | PD-L1 ≥50%, EGFR/ALK negative | No prior systemic therapy for metastatic disease |
| Extensive-stage SCLC | First-line | None specified | Combination with carboplatin/etoposide |
| Hepatocellular carcinoma | First-line | None specified | Combination with bevacizumab, Child-Pugh A |
Common Denial Reasons and Solutions
| Denial Reason | Solution | Documentation Needed |
|---|---|---|
| Insufficient PD-L1 testing | Resubmit with FDA-approved assay results | Lab report with test method and percentage |
| Missing molecular testing | Complete EGFR/ALK testing | Molecular pathology report |
| Non-formulary status | Request formulary exception | Medical necessity letter, failed alternatives |
| Site of care restriction | Request exception or change location | Clinical justification for hospital vs. office |
| Step therapy requirement | Document contraindications to preferred agents | Prior treatment records, intolerance notes |
Internal Appeals with Aetna
If your initial PA is denied, you have 60 days from the denial date to file an internal appeal.
Standard Internal Appeal
Timeline: 30 days for decision
Submit to: Address on denial letter or via provider portal
Include: Original PA, denial letter, additional clinical evidence, peer-reviewed literature
Expedited Appeal
When to use: Delay would seriously jeopardize health
Timeline: 72 hours for decision
Required: Physician certification of urgency
Submit: Same process as standard but mark "URGENT"
Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with Aetna's specific requirements, potentially saving weeks in the appeals process.
Virginia External Review Process
After exhausting Aetna's internal appeals, Virginia residents can request an independent external review through the State Corporation Commission (SCC) Bureau of Insurance.
Eligibility and Timeline
- Deadline: 120 days from Aetna's final internal denial
- Cost: Free to patients
- Decision timeline: 45 days (standard), 72 hours (expedited)
- Binding: Decision is final and binding on Aetna
Required Forms and Submission
Form: SCC Form 216-A (External Review Request) (verify current form)
Submit to: Virginia SCC Bureau of Insurance Consumer Services
Include:
- Completed Form 216-A
- All Aetna denial and appeal letters
- Medical records and test results
- Physician letter of medical necessity
Contact for guidance: Virginia SCC Consumer Services at 1-877-310-6560
Expedited External Review
Virginia allows expedited external review for cancer treatments when delay would seriously jeopardize health, with decisions required within 72 hours.
From our advocates: We've seen cases where Virginia's external review overturned Aetna denials for Tecentriq when the initial PA lacked sufficient PD-L1 documentation. The independent reviewers often focus on whether the clinical evidence clearly supports medical necessity under the plan's own criteria.
Cost Assistance and Patient Support
Manufacturer Support
Genentech Access Solutions
- Copay assistance for eligible patients
- Patient assistance program for uninsured/underinsured
- Contact: 1-855-692-6729
- Website: genentech-access.com
Virginia-Specific Resources
- Virginia Medicaid: Expanded coverage since 2019
- Virginia Health Insurance Marketplace: Premium tax credits available
- Virginia Poverty Law Center: Free legal assistance for coverage appeals
FAQ
How long does Aetna prior authorization take for Tecentriq in Virginia? Standard decisions are made within 15 business days. Expedited requests (when medically urgent) are decided within 72 hours.
What if Tecentriq is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate or have failed.
Can I get expedited review if my cancer is progressing? Yes. Both Aetna's internal expedited appeal (72 hours) and Virginia's expedited external review (72 hours) are available when delay would seriously jeopardize health.
Does step therapy apply if I've tried other immunotherapies outside Virginia? Yes. Aetna's step therapy requirements follow the patient, not the state. Document all prior therapies with dates and outcomes.
What happens if Virginia external review overturns Aetna's denial? Aetna must authorize coverage within 24 hours for expedited cases, or 1-3 days for standard cases. The decision is binding.
How much does Tecentriq cost without insurance? List price is approximately $8,113 per 840mg vial and $11,589 per 1200mg vial, with typical treatment requiring multiple vials per cycle.
Sources & Further Reading
- Aetna Tecentriq Clinical Policy
- Aetna Commercial PA Form
- Aetna Medicare PA Form
- Virginia SCC External Review
- Tecentriq FDA Prescribing Information
- Genentech Access Solutions
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For personalized assistance with complex appeals, Counterforce Health offers specialized support in turning denials into successful authorizations.
Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.