By Counterforce Health Team in Tecentriq (atezolizumab) —

Getting Tecentriq (Atezolizumab) Covered by Cigna in Ohio: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Tecentriq Covered by Cigna in Ohio

Yes, Cigna covers Tecentriq (atezolizumab) in Ohio, but requires prior authorization. Your oncologist must submit clinical documentation including diagnosis, PD-L1 testing (where applicable), and prior therapy history. Standard approval takes 72 hours; expedited reviews within 24 hours if urgent. If denied, you have 180 days to file internal appeals, followed by Ohio's external review process through independent medical experts.

Start today: Have your oncologist submit the PA request via Cigna's provider portal with complete medical records and biomarker testing results.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Clinical Criteria and Requirements
  5. Understanding Your Costs
  6. Denials and Appeals Process
  7. Ohio External Review Rights
  8. Specialty Pharmacy Requirements
  9. Common Questions and Troubleshooting
  10. Resources and Next Steps

Coverage Basics

Is Tecentriq Covered by Cigna?

Tecentriq (atezolizumab) is covered by most Cigna plans in Ohio, but it's typically classified as a specialty medication requiring prior authorization. The drug is managed through Cigna's specialty pharmacy network, primarily Accredo.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Doctor must get approval before prescribing Cigna formulary documents
Specialty Pharmacy Must use Accredo or approved network pharmacy Cigna member portal
Step Therapy May need to try other treatments first Plan-specific policy
PD-L1 Testing Biomarker testing required for certain cancers FDA labeling, NCCN guidelines
Site of Care Infusion location restrictions may apply Coverage determination forms

Prior Authorization Process

Who Submits the Request?

Your oncologist or their office staff must submit the prior authorization request. Patients cannot submit PA requests directly to Cigna.

Step-by-Step: Fastest Path to Approval

  1. Gather Complete Documentation (Clinic responsibility)
    • Diagnosis with ICD-10 codes
    • Pathology reports and staging
    • PD-L1 testing results (if applicable)
    • Prior treatment history and outcomes
    • Current performance status
  2. Submit Via Cigna Provider Portal (Clinic responsibility)
    • Electronic submission preferred
    • Include all required clinical rationale
    • Timeline: Submit within 24-48 hours of prescription
  3. Track Your Request (Patient can help)
    • Use myCigna member portal
    • Call member services: number on your ID card
    • Timeline: Check status after 48 hours
  4. Respond to Information Requests (Both patient and clinic)
    • Cigna may request additional documentation
    • Respond within 24-48 hours to avoid delays
    • Timeline: Usually resolved within 72 hours total

Timing and Deadlines

Standard Review Process

  • Initial Decision: 72 hours from complete submission
  • Expedited Review: 24 hours if medically urgent
  • Information Requests: Additional 24-48 hours if more documentation needed
Note: If Cigna doesn't respond within regulatory timeframes, the request is automatically approved under Ohio insurance law.

When to Request Expedited Review

Your oncologist can request expedited review if:

  • Delay would seriously jeopardize your health
  • You're experiencing rapid disease progression
  • Standard timeline would interfere with treatment schedule

Clinical Criteria and Requirements

Medical Necessity Documentation

Your oncologist must provide:

Diagnosis Requirements:

  • Confirmed cancer diagnosis with appropriate ICD-10 code
  • Disease stage and extent
  • Pathology report confirming diagnosis

Biomarker Testing:

  • PD-L1 expression status (required for certain lung cancer indications)
  • Other molecular testing as indicated (EGFR, ALK, ROS1 for NSCLC)
  • Results must align with FDA-approved indications

Prior Treatment History:

  • Documentation of previous therapies tried
  • Reasons for discontinuation (progression, intolerance, contraindications)
  • Dates and duration of prior treatments
Clinician Corner: Include specific details about treatment failures, not just drug names. Document objective progression (imaging, lab values) and subjective intolerance symptoms with dates and severity.

Common Clinical Criteria by Indication

Non-Small Cell Lung Cancer (NSCLC):

  • PD-L1 testing required for first-line use
  • Documentation of EGFR/ALK testing
  • Performance status (ECOG 0-2 typically required)

Hepatocellular Carcinoma:

  • Child-Pugh Class A liver function
  • Documentation of bevacizumab eligibility assessment
  • Prior systemic therapy history

Small Cell Lung Cancer:

  • Extensive stage disease
  • Combination therapy rationale
  • Performance status documentation

Understanding Your Costs

Commercial Insurance Plans

Manufacturer Copay Assistance:

  • Genentech Co-pay Program may reduce costs to $0 per treatment
  • Only available for commercial (non-government) insurance
  • Annual maximum benefits apply

Typical Cost Structure:

  • Coinsurance: 20-40% of drug cost
  • Monthly out-of-pocket: $500-$2,000+ without assistance
  • Annual out-of-pocket maximum applies

Medicare Advantage Plans

Important Limitation:

  • Manufacturer copay programs not available for Medicare patients
  • Must seek assistance through independent foundations

Foundation Resources:

  • Patient Access Network (PAN) Foundation
  • Patient Advocate Foundation
  • CancerCare Co-Payment Assistance
Tip: Contact Accredo for help connecting with foundation programs and navigating financial assistance options.

Denials and Appeals Process

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Not medically necessary Submit detailed clinical rationale with NCCN guideline references
Missing documentation Provide complete pathology, biomarker testing, and treatment history
Step therapy required Document contraindications or failures of preferred treatments
Off-label use Include FDA labeling and recognized compendia support
Site of care restriction Justify medical necessity for specific infusion location

Internal Appeals Process

First-Level Appeal:

  • Timeline: File within 180 days of denial
  • Decision: Within 30 days (expedited: 72 hours)
  • Submit via: Cigna appeals process

Second-Level Appeal:

  • Available if first appeal denied
  • Timeline: 30 days from first-level denial
  • Decision: Within 30 days

Required Appeal Documentation

  1. Original denial letter
  2. Complete medical records supporting medical necessity
  3. Peer-reviewed literature supporting treatment choice
  4. Provider letter with detailed clinical rationale
  5. Any new clinical information since original request
From our advocates: We've seen appeals succeed when oncologists include specific NCCN guideline citations and explain why standard treatments aren't appropriate for the individual patient's situation. The more specific the clinical rationale, the better the outcome.

Ohio External Review Rights

If Cigna denies your internal appeals, Ohio law provides additional protection through independent medical review.

External Review Process

Eligibility:

  • Must complete Cigna's internal appeal process first
  • Denial must involve medical judgment (not contractual exclusions)
  • Request within 180 days of final internal denial

Timeline:

  • Standard Review: 30 days
  • Expedited Review: 72 hours (if delay endangers health)

How to Request:

  1. Contact Ohio Department of Insurance: 800-686-1526
  2. Submit external review request form
  3. Include all medical documentation
  4. Independent medical experts review your case

Success Rates: External reviews often have higher approval rates than internal appeals, especially for cancer treatments with strong clinical evidence.

Specialty Pharmacy Requirements

Why Specialty Pharmacy?

Cigna requires Tecentriq to be dispensed through specialty pharmacies due to:

  • Complex storage and handling requirements
  • Need for patient monitoring and support
  • Coordination with infusion centers

Accredo Services

Accredo provides:

  • Prior authorization support
  • Insurance benefit verification
  • Financial assistance program enrollment
  • Clinical monitoring and support
  • Coordination with your oncology team

Patient Responsibilities

  • Maintain current contact information with Accredo
  • Respond promptly to refill reminders
  • Report any side effects or concerns
  • Keep insurance information updated

Common Questions and Troubleshooting

How long does Cigna PA take in Ohio?

Standard prior authorization decisions are made within 72 hours of receiving complete documentation. Expedited reviews are completed within 24 hours if your oncologist certifies medical urgency.

What if Tecentriq is non-formulary on my plan?

You can request a formulary exception with clinical justification from your oncologist. The process follows similar timelines to standard prior authorization.

Can I request an expedited appeal?

Yes, if your oncologist certifies that waiting the standard appeal timeline would seriously jeopardize your health. Expedited appeals are decided within 72 hours.

What if I move from another state to Ohio?

Your Cigna coverage typically continues, but you may need to establish care with Ohio-based oncologists and use Ohio-approved infusion centers. Contact Cigna member services to confirm network providers.

Does step therapy apply if I've tried treatments outside Ohio?

Yes, prior treatment history from other states counts toward step therapy requirements. Ensure your new Ohio oncologist has complete records from your previous providers.

Resources and Next Steps

Immediate Action Items

For Patients:

  • Contact your oncologist to initiate PA request
  • Gather insurance cards and policy information
  • Register for myCigna online portal
  • Contact Accredo if Tecentriq is approved

For Oncologists:

  • Collect complete clinical documentation
  • Submit PA via Cigna provider portal
  • Include PD-L1 and other biomarker testing
  • Prepare clinical rationale letter

Key Contacts

  • Cigna Member Services: Number on your ID card
  • Ohio Department of Insurance: 800-686-1526
  • Accredo Specialty Pharmacy: 800-803-2523
  • Genentech Access Solutions: 888-249-4918

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and operational details to improve approval rates and reduce administrative burden.

When to Escalate

Contact the Ohio Department of Insurance if:

  • Cigna doesn't respond within required timeframes
  • You believe the denial violates Ohio insurance law
  • You need help navigating the external review process
  • You encounter procedural barriers to appeals

Additional Support Resources

  • CancerCare: 800-813-4673 (financial assistance and counseling)
  • Patient Advocate Foundation: 800-532-5274 (case management)
  • UHCAN Ohio: Universal Health Care Action Network for consumer advocacy

For complex cases or repeated denials, consider consulting with a patient advocate or healthcare attorney familiar with Ohio insurance law.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and clinical situation. Always verify current requirements with Cigna and consult your healthcare team for medical decisions. For official Ohio insurance regulations, visit the Ohio Department of Insurance website.

Sources:

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.