By Counterforce Health Team in Tecentriq (atezolizumab) —

Getting Tecentriq (Atezolizumab) Covered by Cigna in Florida: Complete Appeals Guide with Forms and Timelines

Answer Box: Quick Path to Tecentriq Coverage

For Cigna Medicare Advantage members in Florida: Tecentriq requires no prior authorization. For other Cigna plans, submit PA through Accredo specialty pharmacy with PD-L1 testing results ≥1% (adjuvant NSCLC) or ≥50% TC/≥10% IC (metastatic). If denied, file internal appeal within 180 days, then external review through Florida DFS within 4 months. Standard response: 30 days internal, 60 days external.

First step today: Verify your specific Cigna plan type and formulary status at cigna.com or call member services.

Table of Contents

  1. Cigna's Coverage Criteria for Tecentriq in Florida
  2. Prior Authorization Requirements by Plan Type
  3. Medical Necessity Documentation
  4. Step Therapy and Exception Pathways
  5. Site of Care and Specialty Pharmacy Rules
  6. Appeals Process: Internal to External Review
  7. Common Denial Reasons and Solutions
  8. Florida-Specific Appeal Timelines
  9. Cost-Saving Programs and Support
  10. FAQ: Tecentriq Coverage Questions

Cigna's Coverage Criteria for Tecentriq in Florida

Plan Types and Policy Application

Cigna covers Tecentriq (atezolizumab) differently across plan types in Florida. Medicare Advantage members benefit from streamlined access—Tecentriq requires no prior authorization under these plans, classified as a Medical Oncology agent without PA requirements.

For commercial plans (employer-sponsored and individual marketplace), Tecentriq typically requires prior authorization through Cigna's specialty drug management process. Medicaid managed care plans in Florida follow similar PA requirements with additional state-specific considerations.

FDA-Approved Indications

Tecentriq is FDA-approved for multiple cancer types, with coverage criteria varying by indication:

  • Adjuvant NSCLC (Stage II-IIIA): Following resection and platinum-based chemotherapy
  • Metastatic NSCLC: First-line for high PD-L1 expression
  • Extensive-stage small cell lung cancer (ES-SCLC): In combination with carboplatin and etoposide
  • Hepatocellular carcinoma: With bevacizumab as first-line treatment
  • Melanoma: In combination with cobimetinib and vemurafenib

Prior Authorization Requirements by Plan Type

Coverage at a Glance

Requirement Medicare Advantage Commercial Plans Medicaid
Prior Authorization Not required Required Required
Formulary Tier Covered Specialty Tier Varies by plan
PD-L1 Testing Per FDA label Required for NSCLC Required for NSCLC
Step Therapy No Varies by indication May apply
Site of Care Restrictions Hospital/clinic infusion Lowest cost appropriate State-approved facilities

Submission Process for Commercial Plans

Prior authorization requests must be submitted to Accredo specialty pharmacy, Cigna's preferred specialty pharmacy provider. Prescribers can submit via:

  • Online: CoverMyMeds portal or SureScripts EHR integration
  • Fax: 888.302.1028
  • Phone: 866.759.1557 for verbal orders

Standard response time is 5 business days. For urgent requests where standard review may jeopardize the patient's health, call (800) 882-4462 and request expedited review.

Medical Necessity Documentation

Required Clinical Evidence

Your oncologist must provide comprehensive documentation demonstrating medical necessity. For adjuvant NSCLC, include:

  • Pathology report confirming NSCLC histology and stage (II-IIIA)
  • PD-L1 testing results showing ≥1% expression using FDA-approved assay
  • Documentation of completed surgical resection
  • Records of completed platinum-based chemotherapy
  • Current performance status assessment

For metastatic NSCLC, documentation must show:

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements for Approval:Problem statement: Specific cancer type, stage, and ICD-10 codePrior treatments: Document therapies tried, outcomes, and progression datesClinical rationale: Why Tecentriq is appropriate for this patient's situationGuideline support: Reference NCCN guidelines or FDA labelingMonitoring plan: How you'll assess response and manage potential adverse effects

Step Therapy and Exception Pathways

When Step Therapy Applies

Step therapy requirements vary by indication. For metastatic NSCLC, patients without EGFR/ALK mutations may proceed directly to Tecentriq if PD-L1 criteria are met. However, some Cigna plans may require documentation of:

  • Previous chemotherapy regimens (if applicable)
  • Contraindications to alternative first-line therapies
  • Disease progression despite prior treatment

Medical Exception Process

If step therapy applies to your situation, request an exception by documenting:

  1. Medical contraindications to required first-line therapies
  2. Previous treatment failures with objective response data
  3. Clinical urgency requiring immediate Tecentriq initiation
  4. Specialist recommendation with supporting rationale

Submit exception requests through the same Accredo portal used for standard PA, clearly marking "STEP THERAPY EXCEPTION REQUEST."

Site of Care and Specialty Pharmacy Rules

Infusion Site Requirements

Cigna requires Tecentriq infusion in the lowest cost, medically appropriate setting. When prescribed for hospital outpatient infusion, your oncologist must evaluate redirection to:

  • Ambulatory infusion sites (AIS)
  • Physician-directed offices with infusion capability
  • Home infusion services (if clinically appropriate)

If hospital-based infusion is medically necessary, provide written justification addressing why alternative sites are inappropriate for your specific clinical situation.

Specialty Pharmacy Routing

All Tecentriq prescriptions route through Accredo specialty pharmacy (NCPDP 4436920). The medication requires special handling including refrigeration and typically ships directly to your infusion site rather than your home.

Accredo contact information:

  • Address: 1620 Century Center Pkwy, Memphis, TN 38134-8822
  • Fax: 888.302.1028
  • Phone: 866.759.1557

Appeals Process: Internal to External Review

Internal Appeal (First Level)

If Cigna denies your Tecentriq prior authorization, you have 180 days from the denial notice to file an internal appeal. Submit appeals to:

Cigna National Appeals Unit
P.O. Box 188011
Chattanooga, TN 37422

Include in your appeal package:

  • Complete denial letter with case reference number
  • Additional clinical documentation supporting medical necessity
  • Peer-reviewed literature supporting Tecentriq use
  • Updated medical necessity letter addressing denial reasons

Cigna responds within 30 days for standard appeals or 72 hours for expedited reviews.

External Review Through Florida DFS

After exhausting Cigna's internal process, you can pursue external review through the Florida Department of Financial Services. This independent review is:

  • Free to consumers
  • Binding on Cigna if overturned
  • Available within 4 months of final internal denial

Florida contracts with independent medical experts to review your case. The external reviewer considers whether Tecentriq is medically necessary and whether Cigna's denial followed policy and medical guidelines.

Common Denial Reasons and Solutions

Denial Reason Required Documentation How to Appeal
"Experimental/Investigational" FDA approval status, clinical trial data Cite FDA labeling and NCCN inclusion
"Insufficient PD-L1 testing" FDA-approved assay results Submit pathology report with specific assay name and expression percentage
"Alternative therapies available" Contraindications to alternatives Document medical reasons why other therapies are inappropriate
"Site of care not appropriate" Medical necessity for hospital infusion Provide clinical justification for infusion setting
"Non-formulary" Formulary exception request Submit prior therapy failures and specialist support

From Our Advocates

We've seen successful appeals when patients include a clear timeline of their cancer journey—diagnosis date, staging, prior treatments with specific dates and outcomes, and current disease status. Insurance reviewers respond well to objective, chronological documentation that tells the complete clinical story without emotional appeals.

Florida-Specific Appeal Timelines

Timeline Overview

Denial Notice → Internal Appeal (180 days) → Response (30 days) → External Review (4 months) → Decision (60 days)

Key Florida Resources

Florida Department of Financial Services

  • Consumer Helpline: (877) 693-5236
  • Online complaint portal: myfloridacfo.com
  • Insurance Consumer Advocate available for systemic issues

Expedited Review Options For life-threatening conditions requiring immediate Tecentriq access:

  • Request expedited internal and external review simultaneously
  • External review decision within 72 hours for urgent cases
  • Document clinical urgency with oncologist attestation

Cost-Saving Programs and Support

Manufacturer Support Programs

Genentech Patient Foundation

  • Provides free Tecentriq for eligible uninsured/underinsured patients
  • Income guidelines and application process available at gene.com

Commercial Insurance Copay Support

  • Genentech offers copay assistance reducing out-of-pocket costs
  • Eligibility restrictions apply (not available for government-funded plans)

State and Federal Programs

Florida residents may qualify for additional support through:

  • Florida Breast and Cervical Cancer Early Detection Program (for eligible cancer types)
  • Medicare Extra Help for prescription drug costs
  • Medicaid for income-eligible individuals

FAQ: Tecentriq Coverage Questions

How long does Cigna prior authorization take in Florida? Standard PA decisions take 5 business days. Expedited reviews for urgent medical situations receive decisions within 72 hours.

What if Tecentriq is non-formulary on my plan? Request a formulary exception through your prescriber, documenting medical necessity and prior therapy failures with alternative agents.

Can I request peer-to-peer review with Cigna's medical director? Yes. Your oncologist can request peer-to-peer discussion during the PA process or appeal. This often resolves complex clinical scenarios more efficiently than written appeals alone.

Does step therapy apply if I failed therapies outside Florida? Previous treatment records from any state count toward step therapy requirements. Ensure your Florida oncologist has complete records from previous providers.

What's the difference between internal and external appeals? Internal appeals are reviewed by Cigna staff. External appeals involve independent medical experts not employed by Cigna, providing an unbiased second opinion.

How do I know if I have Medicare Advantage or commercial Cigna coverage? Check your insurance card for "Medicare" designation or call the member services number on your card. Medicare Advantage members have streamlined Tecentriq access without PA requirements.

When to Get Help

If you're struggling with Cigna's coverage process, consider professional assistance. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements. Their platform pulls appropriate medical citations and weaves them into appeals with required clinical documentation, helping patients, clinicians, and specialty pharmacies get prescription drugs approved more efficiently.

For immediate assistance with Florida insurance issues, contact the Florida Department of Financial Services Consumer Helpline at (877) 693-5236 or file a complaint online at myfloridacfo.com.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific Cigna plan and consult your healthcare provider for medical decisions. For personalized assistance with coverage issues, contact Counterforce Health or your state insurance department.

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