By Counterforce Health Team in Tecentriq (atezolizumab) —

Getting Tecentriq (Atezolizumab) Approved by UnitedHealthcare in Ohio: Complete PA Guide

Answer Box: Fast Track to Tecentriq Approval

UnitedHealthcare requires prior authorization for Tecentriq (atezolizumab) in Ohio through their provider portal at UHCprovider.com. Submit PA requests with complete clinical documentation including PD-L1 testing, staging, and FDA-approved indication alignment. First step today: Have your oncologist gather pathology reports, biomarker results, and treatment history, then submit via the online PA tool for fastest processing (typically 10-14 business days, expedited ≤72 hours for urgent cases).

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Cost-Share Basics
  6. Submission Process
  7. Common Approval Patterns
  8. Appeals Playbook for Ohio
  9. FAQ
  10. Sources & Further Reading

Plan Types & Coverage Implications

UnitedHealthcare operates multiple plan types in Ohio, each with distinct coverage pathways for Tecentriq:

UnitedHealthcare Community Plan of Ohio (Medicaid)

Commercial Plans (HMO/PPO/EPO)

  • Coverage varies by employer group and formulary tier
  • Typically requires PA through OptumRx for specialty oncology drugs
  • No documented step therapy requirements for Tecentriq specifically

Medicare Advantage

Note: Self-funded employer plans follow federal ERISA rules, while fully-insured plans use Ohio's external review process after internal appeals are exhausted.

Formulary Status & Tier Placement

Coverage at a Glance

Requirement What It Means Where to Find It Source
PA Required Yes, all plans Provider portal PA tool UHC Ohio PA Lists
Formulary Tier Medical benefit (not pharmacy) Plan-specific formulary Member portal
Step Therapy None documented OptumRx drug lists OptumRx ST Programs
Quantity Limits 1,680 mg max dose Ohio dosage policy UHC Dosage Limits
Site of Care Infusion centers only Network directory Provider portal

Tecentriq is classified under UnitedHealthcare's Oncology Medication Clinical Coverage policy for Ohio, indicating it falls under medical benefits rather than pharmacy benefits. This means it's administered at approved infusion centers and billed under HCPCS code J9022.

Prior Authorization Requirements

Clinical Documentation Checklist

Required for All Submissions:

  • FDA-approved indication with specific cancer type and staging
  • PD-L1 expression testing results (with assay method)
  • Complete pathology report with ICD-10 diagnosis codes
  • ECOG performance status
  • Prior treatment history and outcomes
  • Contraindication documentation for alternative therapies

Indication-Specific Requirements:

Cancer Type Additional Requirements
NSCLC EGFR/ALK mutation status, TNM staging
SCLC Extensive-stage confirmation, combo therapy rationale
Hepatocellular Child-Pugh score, bevacizumab eligibility assessment
Melanoma BRAF mutation status if applicable

Medical Necessity Criteria

Based on UnitedHealthcare's oncology coverage policies, Tecentriq approval typically requires:

  1. FDA labeling alignment: Treatment must match approved indications
  2. Biomarker requirements: PD-L1 expression testing where indicated
  3. Performance status: ECOG 0-2 for most indications
  4. Prior therapy documentation: Evidence of progression or intolerance to standard treatments
  5. Contraindication assessment: Documentation why alternatives aren't suitable

Specialty Pharmacy Network

Tecentriq requires IV infusion and isn't dispensed through traditional specialty pharmacies. Instead, UnitedHealthcare coordinates through approved infusion centers in Ohio.

Known Ohio Infusion Network Partners:

  • Ohio Infusion Services, Mayfield Heights: 5915 Landerbrook Dr, 216-381-3333
Tip: Contact UnitedHealthcare provider services at 1-844-640-6446 to verify current network infusion centers in your area, as the network updates regularly.

Patient Setup Process:

  1. Oncologist submits PA request with clinical documentation
  2. UnitedHealthcare approves site of care (infusion center)
  3. Infusion center coordinates with Genentech for drug supply
  4. Patient schedules treatment at approved facility

Cost-Share Basics

Since Tecentriq is a medical benefit (Part B for Medicare, medical for commercial), cost-sharing follows your plan's medical deductible and coinsurance structure rather than pharmacy copays.

Typical Cost Structure:

  • Deductible: Applied if not yet met for the year
  • Coinsurance: Usually 10-30% after deductible
  • Out-of-pocket maximum: Counts toward annual limit

Financial Assistance Options:

  • Genentech Patient Foundation: Income-based assistance
  • Copay assistance programs for commercial insurance
  • Medicare Part B Extra Help for qualifying beneficiaries
Important: Cost estimates are educational only. Contact your plan directly for specific benefit information.

Submission Process

Step-by-Step: Fastest Path to Approval

1. Verify Eligibility (Provider)

  • Log into UHCprovider.com
  • Check member eligibility and benefits
  • Confirm Tecentriq requires PA for the specific plan

2. Gather Clinical Documentation (1-3 days)

  • Complete pathology report with staging
  • PD-L1 testing results and methodology
  • Prior treatment records and outcomes
  • Current imaging and lab results
  • ECOG performance status assessment

3. Submit PA Request Online

  • Access Prior Authorization and Notification tool in provider portal
  • Select oncology drug category
  • Upload all clinical documentation
  • Include specific HCPCS code (J9022) and dosing schedule

4. Track Status

  • Standard review: 10-14 business days
  • Expedited review: ≤72 hours for urgent cases
  • Check portal for determination or additional information requests

Alternative Submission Methods:

  • Phone: 888-397-8129 or 888-702-2202
  • Fax: 866-968-7582 (use forms from prior authorization forms page)

Clinician Corner: Medical Necessity Letter

Essential Elements for Strong Submissions:

Medical Necessity Template Components:Patient demographics and insurance informationPrimary diagnosis with ICD-10 codes and stagingRelevant biomarker results (PD-L1, mutations)Treatment history with dates, drugs, and outcomesClinical rationale citing NCCN guidelines or FDA labelingSpecific dosing regimen and administration planExpected treatment duration and monitoring plan

Include direct quotes from FDA labeling and reference NCCN Category 1 recommendations where applicable.

Common Approval Patterns

Based on UnitedHealthcare's oncology policies and Medicare Advantage data showing 81.7% appeal success rates, strong submissions typically include:

What Successful PAs Include

Clinical Strength Indicators:

  • Complete biomarker panel results
  • Clear progression documentation on prior therapies
  • ECOG performance status 0-2
  • Multidisciplinary team treatment plan
  • Site-of-care coordination confirmed

Documentation Quality:

  • Timestamped clinical notes
  • Radiology reports showing progression
  • Laboratory values supporting treatment candidacy
  • Prior authorization forms completely filled

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
Insufficient clinical information Resubmit with complete records Full pathology, staging, biomarkers
Off-label use Provide compendia support NCCN guidelines, peer-reviewed studies
Alternative therapy available Document contraindications Allergy records, prior failure documentation
Site of care not approved Request network exception Medical necessity for specific facility

Appeals Playbook for Ohio

UnitedHealthcare Internal Appeals

Level 1 Appeal (Standard)

  • Deadline: 180 days from denial date
  • Submission: Provider portal or fax to appeals department
  • Timeline: 30 days for determination
  • Success rate: ~82% for oncology drugs based on MA data

Level 2 Appeal (Independent Review)

  • Deadline: 60 days from Level 1 denial
  • Process: Independent medical reviewer
  • Timeline: 30 days for determination

Ohio External Review Process

After exhausting internal appeals, Ohio residents can request external review:

Eligibility: Medical necessity denials (not contractual exclusions) Deadline: 180 days from final internal denial Process: File with UnitedHealthcare, who forwards to Ohio Department of Insurance Timeline: 30 days standard, 72 hours expedited Authority: Ohio Department of Insurance at 1-800-686-1526

Ohio-Specific Advantage: Even if UnitedHealthcare claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

Appeal Scripts & Templates

Patient Phone Script for UnitedHealthcare: "I'm calling to appeal the denial of Tecentriq for my [cancer type]. My claim number is [X]. I believe this is medically necessary because [brief clinical rationale]. Can you please provide me with the specific appeal forms and deadline?"

Clinic Staff Peer-to-Peer Request: "I'm requesting a peer-to-peer review for [patient name] regarding Tecentriq denial. The patient has [indication] with [biomarker status] and has progressed on [prior therapies]. When can we schedule the medical director call?"

When to Escalate

Contact Ohio regulators if you encounter:

  • Delayed processing beyond stated timelines
  • Requests for inappropriate clinical information
  • Denial of expedited review for urgent cases
  • Blocking of external review process

Ohio Department of Insurance Consumer Services: 1-800-686-1526 Complaint filing: Available online at insurance.ohio.gov

FAQ

How long does UnitedHealthcare PA take in Ohio? Standard prior authorization: 10-14 business days. Expedited review for urgent cases: ≤72 hours. Submit via the provider portal for fastest processing.

What if Tecentriq is non-formulary on my plan? Tecentriq is typically covered as a medical benefit rather than pharmacy formulary. Request a formulary exception with clinical documentation showing medical necessity.

Can I request an expedited appeal in Ohio? Yes, if delay would seriously endanger your health. Both UnitedHealthcare internal appeals and Ohio external review offer expedited timelines (≤72 hours).

Does step therapy apply if I've failed therapies outside Ohio? No documented step therapy requirements exist for Tecentriq. However, document prior treatment failures clearly, regardless of where they occurred.

What happens if my employer plan is self-funded? Self-funded plans follow federal ERISA rules rather than Ohio external review. However, many voluntarily use similar independent review processes.

How much does Tecentriq cost with UnitedHealthcare? Costs depend on your specific plan's medical deductible and coinsurance. Contact member services for benefit-specific estimates. Financial assistance may be available through Genentech programs.

From our advocates: We've seen Tecentriq approvals succeed when providers include comprehensive biomarker testing results and clearly document why alternative therapies aren't appropriate. The key is painting a complete clinical picture rather than just meeting minimum requirements. This approach has helped streamline approvals even for complex cases.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific basis for rejection, and drafts targeted rebuttals using the payer's own coverage rules and evidence-backed clinical documentation.

Whether you're facing a Tecentriq denial or navigating prior authorization requirements, having the right clinical evidence and procedural knowledge makes all the difference. Counterforce Health specializes in creating compelling medical necessity cases that meet UnitedHealthcare's specific documentation requirements while tracking all procedural deadlines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for specific guidance. Ohio insurance regulations and UnitedHealthcare policies may change; verify current requirements through official sources.

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