By Counterforce Health Team in Tecentriq (atezolizumab) —

Get Tecentriq (Atezolizumab) Covered by Humana in Virginia: Complete Prior Authorization & Appeals Guide

Answer Box: Quick Path to Coverage

Tecentriq (atezolizumab) requires prior authorization from Humana and must be dispensed through specialty pharmacies like CenterWell. In Virginia, if denied, you have 65 days to appeal and can request expedited external review through the State Corporation Commission if delays risk serious harm.

First steps today:

  1. Have your oncologist submit prior authorization to Humana with complete clinical documentation
  2. Send prescription to CenterWell Specialty Pharmacy
  3. If denied, file appeal within 65 days using Humana's redetermination form

For urgent cases, Virginia allows expedited external review within 72 hours.

Table of Contents

  1. Humana's Coverage Policy for Tecentriq
  2. Prior Authorization Requirements
  3. Specialty Pharmacy Network
  4. Step-by-Step: Fastest Path to Approval
  5. Common Denial Reasons & Solutions
  6. Appeals Process in Virginia
  7. Cost and Financial Assistance
  8. When to Contact Virginia Regulators
  9. FAQ

Humana's Coverage Policy for Tecentriq

Plan Types & Coverage Status

Humana covers Tecentriq (atezolizumab) under both Medicare Advantage and commercial plans, but with strict utilization management. The drug appears on Humana's Medicare Preauthorization List with HCPCS code J9022, meaning coverage requires prior authorization.

Formulary Status & Tier Placement

  • Medicare Advantage: Covered as Part B specialty drug with prior authorization
  • Commercial plans: Typically placed on high specialty tier (often Tier 5) with coinsurance
  • Step therapy: May apply under Humana's Part B step therapy program, where Tecentriq is classified as "nonpreferred"

Coverage at a Glance

Requirement What it Means Where to Find It
Prior Authorization Required for all Humana plans Medicare PAL
Specialty Pharmacy Must use CenterWell or approved network pharmacy Provider portal
Step Therapy May require trial of preferred agents first Step therapy list
FDA-Approved Use Coverage limited to labeled indications FDA label

Prior Authorization Requirements

Clinical Documentation Checklist

Required for all submissions:

  • Cancer diagnosis with ICD-10 code
  • Disease stage and histology
  • Prior treatment history and outcomes
  • Medical necessity justification
  • Prescriber credentials and contact information

Indication-specific requirements:

  • NSCLC: PD-L1 testing results via FDA-approved assay (TC ≥50% or IC ≥10% for first-line monotherapy; ≥1% for adjuvant)
  • TNBC: PD-L1 expression via FDA-approved test
  • SCLC: No biomarker requirement for first-line combination therapy
  • Prior therapy failures: Documentation of platinum-based chemotherapy failure for second-line use
Clinician Corner: Medical necessity letters should reference NCCN guidelines and include specific biomarker results. Counterforce Health helps providers create evidence-backed appeals that align with payer requirements and reduce approval times.

Submission Process

Submit prior authorization through:

  • Humana provider portal (fastest option)
  • Fax: Use forms from Humana's PA page
  • Phone: For urgent cases requiring expedited review

Response timelines:

  • Standard: 72 hours
  • Expedited: 24 hours (requires urgency documentation)

Specialty Pharmacy Network

CenterWell Specialty Pharmacy

Humana requires Tecentriq to be dispensed through its specialty pharmacy network, primarily CenterWell Specialty Pharmacy. The specialty pharmacy coordinates directly with your infusion center.

Patient enrollment process:

  1. Oncologist sends prescription to CenterWell
  2. CenterWell contacts patient for enrollment (demographics, insurance verification)
  3. Pharmacy coordinates shipping to infusion site
  4. Clinical counseling and adherence support provided

Step-by-Step: Fastest Path to Approval

  1. Verify benefits (Patient/Clinic): Call Humana member services to confirm PA requirements and specialty pharmacy network
  2. Gather documentation (Clinic): Collect diagnosis, staging, biomarker results, prior treatments, and treatment plan
  3. Submit PA (Prescriber): Use Humana provider portal with complete clinical packet; mark expedited if urgent
  4. Send prescription (Prescriber): Submit to CenterWell Specialty Pharmacy simultaneously with PA
  5. Monitor status (Clinic): Check PA status within 24-48 hours; follow up if needed
  6. Coordinate infusion (CenterWell): Pharmacy ships drug to approved infusion center
  7. Begin treatment (Patient): Receive first infusion once PA approved and drug delivered

Common Denial Reasons & Solutions

Denial Reason Solution
Insufficient clinical documentation Resubmit with complete staging, biomarkers, prior therapies
Step therapy not met Document failure/contraindication to preferred agents; request exception
Off-label use Provide NCCN or compendia support; cite peer-reviewed evidence
Missing PD-L1 testing Submit FDA-approved assay results with specific percentage
Non-formulary status Request formulary exception with medical necessity letter
From our advocates: We've seen cases where initial denials were overturned simply by including the specific PD-L1 percentage and FDA-approved test name in the resubmission. Small documentation details can make the difference between approval and denial.

Appeals Process in Virginia

Humana Internal Appeals

If your Tecentriq prior authorization is denied, you have 65 calendar days from the denial notice to file an appeal with Humana.

Required documents:

Filing options:

  • Online through Humana member portal
  • Mail/fax using addresses on redetermination form
  • Phone for expedited appeals

Virginia External Review

After exhausting Humana's internal appeals, Virginia residents can request external review through the State Corporation Commission Bureau of Insurance.

Key Virginia advantages:

  • 120 days to file external review after final internal denial
  • Expedited review available for cancer treatments (72 hours)
  • Free process with independent medical review
  • Binding decision on insurance company

Required forms:

  • Form 216-A (External Review Request)
  • Form 216-C (Physician Certification for expedited review)

Contact Virginia Bureau of Insurance:

  • Phone: (804) 371-9747
  • Online portal for form submission
  • Consumer services staff provide guidance before filing

Timeline for Virginia Appeals

Stage Timeframe Action Required
Internal Appeal 65 days to file Submit Humana redetermination form
Humana Decision 7 days standard, 72 hours expedited Monitor for response
External Review 120 days to file Submit Form 216-A to Virginia SCC
IRO Decision 45 days standard, 72 hours expedited Independent medical review

Cost and Financial Assistance

Medicare Advantage Members

Typical costs:

  • Tecentriq list price: ~$8,113 per 840mg vial, ~$11,589 per 1200mg vial
  • Medicare coinsurance: 20% after deductible
  • Annual out-of-pocket maximum provides cost protection

Financial assistance options:

  • CancerCare Co-Payment Assistance Foundation
  • Patient Advocate Foundation
  • Hospital financial assistance programs
  • State and local cancer foundations
Note: Medicare members are not eligible for Genentech's manufacturer copay assistance program.

Commercial Plan Members

When to Contact Virginia Regulators

Contact the Virginia State Corporation Commission Bureau of Insurance if:

  • Humana fails to respond to appeals within required timeframes
  • You believe the denial violates Virginia insurance law
  • You need guidance on the external review process
  • The insurance company doesn't comply with a favorable external review decision

Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft evidence-backed rebuttals aligned to each plan's requirements.

FAQ

How long does Humana prior authorization take for Tecentriq in Virginia? Standard PA decisions take 72 hours; expedited requests are decided within 24 hours when urgency is documented by the prescriber.

What if Tecentriq is non-formulary on my Humana plan? You can request a formulary exception by demonstrating medical necessity and that formulary alternatives are inappropriate for your condition.

Can I request an expedited appeal in Virginia? Yes, Virginia allows expedited external review within 72 hours if your physician certifies that delays could seriously jeopardize your health.

Does step therapy apply if I've already failed other immunotherapies? Document prior treatment failures and contraindications to request a step therapy exception. Include specific dates, doses, and reasons for discontinuation.

What happens if Virginia's external review overturns Humana's denial? Humana must provide coverage within 1-3 days. For expedited reviews, authorization must occur within 24 hours.

Who can file an appeal on my behalf? You, your appointed representative, or your prescribing physician can file appeals with Humana. Use the Appointment of Authorized Representative form if needed.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances, plan specifics, and clinical factors. Always consult your healthcare provider and insurance company for guidance specific to your situation. For additional support with Virginia insurance issues, contact the State Corporation Commission Bureau of Insurance at (804) 371-9747.

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