By Counterforce Health Team in Tecentriq (atezolizumab) —

Get Tecentriq (Atezolizumab) Covered by Blue Cross Blue Shield in Virginia: Complete Prior Authorization Guide

Answer Box: Tecentriq (atezolizumab) requires prior authorization from Blue Cross Blue Shield in Virginia for all 2024 plans. Success depends on meeting FDA-approved indication criteria, proper PD-L1 testing (≥1% for adjuvant NSCLC, ≥50% for first-line metastatic), and comprehensive documentation. If denied, you have 120 days to file an external review with Virginia's Bureau of Insurance using Form 216-A. Start by having your oncologist submit a detailed letter of medical necessity through Anthem's Availity portal.

Table of Contents

  1. Set Your Goal: Understanding Approval Requirements
  2. Visit Prep: Gathering Your Medical History
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Your Doctor's Peer-to-Peer Review
  6. After Your Visit: Documentation and Follow-up
  7. Respectful Persistence: When and How to Follow Up
  8. Virginia Appeals Process
  9. Cost Savings Options
  10. FAQ

Set Your Goal: Understanding Approval Requirements

Getting Tecentriq approved by Blue Cross Blue Shield in Virginia requires meeting specific clinical criteria and following proper procedures. Here's what you need to know upfront.

Coverage Requirements at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all BCBS Virginia plans Anthem Provider Portal
PD-L1 Testing ≥1% for adjuvant NSCLC, ≥50% for first-line metastatic FDA Tecentriq Label
Mutation Testing Must exclude EGFR/ALK mutations FDA-approved companion diagnostics
Formulary Status Specialty tier requiring PA BCBS Virginia formulary
Site of Care Outpatient infusion center or hospital Medical policy requirements

Your Partnership Strategy

Success requires close collaboration with your oncology team. You'll provide the personal medical history and symptom timeline, while your doctor handles the clinical justification and submission process. This partnership approach significantly improves approval rates.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals. Their platform helps oncology practices navigate complex prior authorization requirements like those for Tecentriq.

Visit Prep: Gathering Your Medical History

Before your appointment, compile a comprehensive timeline of your cancer journey. This preparation saves time and ensures nothing important gets missed.

Essential Information to Gather

Diagnosis Timeline

  • Date of initial cancer diagnosis
  • Staging information and test results
  • Biopsy and pathology reports
  • PD-L1 expression test results
  • EGFR, ALK, and other mutation testing

Treatment History

  • All prior therapies (chemotherapy, radiation, surgery)
  • Dates of treatment and duration
  • Reasons for stopping each treatment
  • Side effects experienced
  • Response to treatment (stable, progression, partial response)

Current Status

  • Recent imaging results (CT, PET scans)
  • Laboratory values
  • Performance status and daily functioning
  • Symptoms affecting quality of life
  • Any contraindications to other treatments
Tip: Create a simple timeline document with dates, treatments, and outcomes. This becomes invaluable for the medical necessity letter.

Building Your Evidence Kit

Your evidence kit supports the medical necessity case for Tecentriq. While your oncologist will handle the clinical aspects, having organized records speeds the process.

Required Documentation

Laboratory and Imaging

  • Most recent staging scans
  • PD-L1 expression results using FDA-approved assay (VENTANA SP263)
  • Complete blood count and metabolic panel
  • Liver and kidney function tests

Treatment Records

  • Discharge summaries from prior treatments
  • Pathology reports confirming diagnosis
  • Documentation of treatment failures or intolerances
  • Any emergency department visits related to cancer progression

Insurance Information

  • Current Blue Cross Blue Shield card
  • Policy number and group information
  • Previous prior authorization decisions
  • Explanation of Benefits (EOB) statements

Clinical Guidelines Reference

Your oncologist will reference established treatment guidelines, particularly:

  • FDA-approved indications for Tecentriq
  • National Comprehensive Cancer Network (NCCN) guidelines
  • American Society of Clinical Oncology (ASCO) recommendations

Medical Necessity Letter Structure

The medical necessity letter is the cornerstone of your prior authorization request. Here's what your oncologist should include:

Essential Components

Patient Information Section

  • Full name, date of birth, insurance details
  • Cancer diagnosis with ICD-10 code
  • Date of diagnosis and staging

Clinical Rationale

  • Why Tecentriq is appropriate for your specific situation
  • How you meet FDA-approved indication criteria
  • PD-L1 testing results and methodology used
  • Absence of contraindications

Treatment History

  • Previous therapies attempted
  • Reasons for discontinuation (progression, toxicity, intolerance)
  • Documentation of treatment failures

Supporting Evidence

  • Reference to FDA approval and clinical trials
  • Alignment with NCCN guidelines
  • Risk-benefit analysis specific to your case
Clinician Corner: Include specific dosing (840 mg every 2 weeks, 1200 mg every 3 weeks, or 1680 mg every 4 weeks), planned duration, and monitoring parameters. Reference the VENTANA PD-L1 (SP263) assay results and confirm absence of EGFR/ALK mutations where required.

Supporting Your Doctor's Peer-to-Peer Review

If the initial prior authorization is denied, your oncologist may request a peer-to-peer review with Blue Cross Blue Shield's medical director.

How You Can Help

Provide Availability Windows Let your doctor know when you're available for urgent treatment if the review is successful. This demonstrates the time-sensitive nature of cancer care.

Prepare a Concise Case Summary Work with your care team to create a one-page summary highlighting:

  • Your diagnosis and stage
  • Why previous treatments failed
  • How Tecentriq specifically addresses your cancer type
  • Impact of treatment delays on your prognosis

Peer-to-Peer Timeline

Blue Cross Blue Shield requires peer-to-peer requests within seven business days of denial. The review focuses on clinical discussion between physicians and doesn't automatically overturn the denial—formal appeals may still be necessary.

After Your Visit: Documentation and Follow-up

Proper documentation after your oncology visit ensures smooth processing and creates a paper trail for potential appeals.

What to Save

Visit Documentation

  • After-visit summary from your oncologist
  • Any new test orders or results
  • Updated treatment plans
  • Prescription information

Communication Records

  • Portal messages with your care team
  • Phone call summaries
  • Correspondence with insurance

Portal Communication Tips

When messaging through your healthcare system's patient portal:

  • Be specific about insurance-related questions
  • Ask for copies of submitted prior authorization requests
  • Request updates on approval status
  • Document any verbal communications in writing

Respectful Persistence: When and How to Follow Up

Cancer treatment is time-sensitive, making appropriate follow-up essential. Here's how to stay engaged without overwhelming your care team.

Follow-up Timeline

Week 1: Initial submission by oncologist Week 2: Check on submission status if no response Week 3: Escalate if still pending, discuss appeal options Week 4+: File formal appeal if denied

Escalation Steps

  1. Contact your oncologist's office for status updates
  2. Call Blue Cross Blue Shield member services directly
  3. Request expedited review if medically urgent
  4. File external review with Virginia Bureau of Insurance
From our advocates: We've seen patients succeed by maintaining a simple tracking spreadsheet with dates, contacts, and outcomes. One patient's organized approach helped identify a processing delay that, once corrected, led to same-day approval. The key is being methodical without being pushy.

Virginia Appeals Process

Virginia provides robust consumer protections for insurance denials through the State Corporation Commission Bureau of Insurance.

External Review Process

Eligibility: Denials based on medical necessity or experimental treatment determinations Timeline: Must file within 120 days of final denial Forms: Complete Form 216-A (External Review Request) Cost: Free to consumers

Step-by-Step Appeals Process

  1. Complete Internal Appeals: Exhaust Blue Cross Blue Shield's internal appeal process first
  2. Gather Documentation: Collect denial letters, medical records, and insurance information
  3. Submit Form 216-A: File with Virginia Bureau of Insurance within 120 days
  4. Independent Review: Case assigned to external medical reviewer
  5. Decision: Standard review completed within 45 days; expedited within 72 hours

Contact Information

Virginia Bureau of Insurance

  • Phone: 1-877-310-6560
  • Email: [email protected]
  • Fax: (804) 371-9915
  • Address: P.O. Box 1157, Richmond, VA 23218

Forms: Available at Virginia SCC External Review page

Cost Savings Options

Even with insurance coverage, Tecentriq can involve significant out-of-pocket costs. Several programs may help reduce your financial burden.

Manufacturer Support

Genentech Patient Foundation

  • Income-based assistance for qualifying patients
  • Copay support programs for commercially insured patients
  • Free drug programs for uninsured patients meeting criteria

State and Federal Programs

Virginia Medicaid: Expanded coverage available for qualifying adults Medicare Extra Help: Assistance with prescription drug costs 340B Program: Discounted pricing at qualifying healthcare facilities

Additional Resources

Patient advocacy organizations often provide grants or emergency assistance for cancer medications. Check with the Leukemia & Lymphoma Society, CancerCare, and similar organizations.

FAQ

How long does Blue Cross Blue Shield prior authorization take in Virginia? Standard prior authorization decisions are typically made within 2-5 business days. Complex cases may take up to 14 days. Expedited reviews for urgent medical situations can be completed within 24-72 hours.

What if Tecentriq is non-formulary on my Blue Cross Blue Shield plan? You can request a formulary exception through the same prior authorization process. Your oncologist will need to demonstrate medical necessity and explain why formulary alternatives aren't appropriate for your specific case.

Can I request an expedited appeal in Virginia? Yes, expedited external reviews are available when delay could seriously jeopardize your health. Your physician must certify the urgency, and decisions are made within 72 hours for medical necessity denials.

Does step therapy apply if I've already failed treatments outside Virginia? Treatment history from other states should be accepted if properly documented. Ensure your oncologist includes complete records of previous therapies and their outcomes in the prior authorization request.

What happens if my external review is denied? The external review decision is binding on your insurance company. If upheld, you may consider legal consultation, employer appeals (for self-funded plans), or alternative treatment options with your oncologist.

How much does Tecentriq cost without insurance? List prices range from approximately $8,113 per 840-mg vial to $11,589 per 1200-mg vial. Monthly costs can exceed $15,000 depending on dosing schedule and treatment duration.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Treatment decisions should be made in consultation with your healthcare provider. Insurance policies and state regulations may change—verify current requirements with official sources.

When navigating complex prior authorization requirements, Counterforce Health provides specialized support for patients and providers, helping transform insurance denials into successful approvals through targeted, evidence-based appeals.

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