By Counterforce Health Team in Tecentriq (atezolizumab) —

Getting Tecentriq (Atezolizumab) Covered by Humana in Pennsylvania: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Quick Start for Tecentriq Coverage

Tecentriq (atezolizumab) is covered by Humana in Pennsylvania but requires prior authorization and is placed on Tier 4 (specialty tier). Your fastest path to approval: 1) Have your oncologist submit a prior authorization request with PD-L1 testing results, mutation testing, and treatment history through Humana's provider portal, 2) If denied, file an internal appeal within 60 days, then 3) Use Pennsylvania's Independent External Review Program (53% overturn rate) for commercial plans or Medicare's federal appeals process for Medicare Advantage plans.

First step today: Contact your oncologist's office to confirm they have all required test results and ask them to initiate the prior authorization process immediately.

Table of Contents

  1. Coverage Overview: What Humana Requires
  2. Prior Authorization Requirements
  3. Step-by-Step Approval Process
  4. Cost and Assistance Options
  5. Appeals Process for Pennsylvania
  6. Common Denial Reasons and Solutions
  7. Pharmacy and Dispensing Requirements
  8. Renewal and Ongoing Coverage

Coverage Overview: What Humana Requires

Tecentriq (atezolizumab) is included in Humana Medicare Advantage formularies as a specialty drug requiring prior authorization. The medication is classified as Tier 4 (specialty tier), which typically carries the highest cost-sharing for patients.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all indications Humana PA List
Formulary Tier Tier 4 (Specialty) Humana Drug Lists
Step Therapy May apply depending on indication Humana Step Therapy List
Specialty Pharmacy CenterWell Specialty required CenterWell Info
Prescriber Requirements Oncologist typically required Plan-specific criteria

Prior Authorization Requirements

Humana requires comprehensive medical documentation for Tecentriq approval. Your oncologist must submit specific clinical evidence depending on your cancer type.

Required Documentation

For All Indications:

  • Confirmed cancer diagnosis with staging
  • ICD-10 diagnosis codes
  • Treatment history and prior therapy failures
  • Prescriber attestation from an oncologist

For Non-Small Cell Lung Cancer (NSCLC):

  • PD-L1 testing results from FDA-approved test showing:
    • First-line treatment: ≥50% tumor cells OR ≥10% tumor-infiltrating immune cells
    • Adjuvant therapy: ≥1% tumor cells
  • Mutation testing confirming absence of EGFR or ALK genomic aberrations
  • Documentation of platinum-based chemotherapy completion (for adjuvant) or failure (for metastatic)

For Hepatocellular Carcinoma:

  • Child-Pugh Class A liver function
  • ECOG performance status 0-1
  • Plan for combination with bevacizumab (if applicable)
Clinician Corner: Medical necessity letters should reference FDA labeling, NCCN guidelines, and include specific biomarker results. Template forms are available through Genentech Access Solutions to streamline submissions.

Step-by-Step Approval Process

Fastest Path to Approval

  1. Gather Required Tests (Patient/Clinic)
    • Ensure PD-L1 and mutation testing are complete
    • Collect all prior treatment records
    • Timeline: 1-2 weeks if tests needed
  2. Submit Prior Authorization (Oncologist)
    • Use Humana provider portal or fax forms
    • Include all required documentation
    • Timeline: Same day submission possible
  3. Await Initial Decision (Humana)
    • Standard review: 14 calendar days
    • Expedited review: 72 hours (for urgent cases)
    • Decision communicated to prescriber and patient
  4. If Approved (Patient/Pharmacy)
    • Coordinate with CenterWell Specialty Pharmacy
    • Schedule delivery or pickup
    • Timeline: 3-5 business days
  5. If Denied (See Appeals Process)
    • Request internal appeal within 60 days
    • Consider peer-to-peer review
    • Prepare for external review if needed

Cost and Assistance Options

Tecentriq's high cost—approximately $8,113 per 840mg vial—makes financial assistance crucial for most patients.

Manufacturer Support

Genentech Co-pay Assistance Program

  • Commercial insurance patients: Up to significant cost reduction
  • Medicare patients: NOT eligible due to federal regulations
  • Enrollment: Call 888-249-4918 or visit Genentech Access

Independent Foundation Assistance

Medicare patients excluded from manufacturer programs may qualify for:

  • Patient Advocate Foundation Co-Pay Relief Program
  • CancerCare Co-Payment Assistance Foundation
  • Leukemia & Lymphoma Society Co-Pay Assistance Program
Note: Foundation funding is limited and based on diagnosis, income, and available funds. Apply early in your treatment cycle.

Humana-Specific Cost Management

  • Specialty pharmacy coordination through CenterWell can help optimize delivery timing
  • Prior authorization approval reduces out-of-pocket to your plan's specialty tier copay
  • Annual out-of-pocket maximums cap total yearly costs

Appeals Process for Pennsylvania

Pennsylvania offers two distinct appeal pathways depending on your Humana plan type.

For Commercial Humana Plans

Pennsylvania Independent External Review Program

  • Success rate: 53% of appeals result in overturned denials
  • Timeline: Under 60 days total
  • Process: Must complete Humana internal appeal first

Steps:

  1. File internal appeal with Humana (60 days from denial)
  2. Receive Final Adverse Benefit Determination
  3. Submit external review request within 4 months
  4. Pennsylvania Insurance Department determines eligibility (5 business days)
  5. Independent review organization assigned (15 days for documentation)
  6. Final binding decision (45 calendar days)

Contact: Pennsylvania Insurance Department at 1-877-881-6388 or pa.gov external review portal

For Humana Medicare Advantage Plans

Federal Medicare Appeals Process

  • Level 1: Plan reconsideration (7 days standard, 72 hours expedited)
  • Level 2: Independent Review Entity (IRE)
  • Deadlines: 60 days for standard appeals, 65 days from denial notice

Contact: 1-800-MEDICARE or your plan's member services

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing PD-L1 testing Submit FDA-approved test results Laboratory report with % expression
Insufficient mutation testing Provide EGFR/ALK testing Molecular pathology report
Step therapy not completed Document failure/intolerance of preferred agents Treatment notes, adverse event records
Non-formulary status Request formulary exception Medical necessity letter, clinical guidelines
Site of care restriction Justify outpatient infusion center Facility accreditation, clinical rationale

Appeal Scripts

For Humana Member Services: "I'm calling to file an internal appeal for a prior authorization denial for Tecentriq. My member ID is [number]. The denial was dated [date]. I'd like to request an expedited appeal due to the urgent nature of my cancer treatment. Can you provide the appeal form and fax number?"

For Peer-to-Peer Review: "Dr. [Name], I'm requesting a peer-to-peer review for my patient's Tecentriq prior authorization denial. The patient has [diagnosis] with [biomarker results] and has failed [prior treatments]. Per NCCN guidelines, Tecentriq is the appropriate next-line therapy."

Pharmacy and Dispensing Requirements

Tecentriq must be dispensed through Humana's specialty pharmacy network, primarily CenterWell Specialty Pharmacy.

Dispensing Process

  1. Prior authorization approval received
  2. CenterWell coordination with prescriber for delivery
  3. Cold-chain shipping directly to treatment facility
  4. Clinical support and adherence monitoring included

Key Contacts

  • CenterWell Specialty: 1-800-379-0092
  • Humana Pharmacy Services: Available through member portal
  • Provider portal: For prescription transmission and status updates
Tip: Coordinate delivery timing with your infusion appointments. CenterWell can schedule deliveries to arrive 1-2 days before treatment to ensure medication availability.

Renewal and Ongoing Coverage

Prior authorization approvals typically last 6-12 months and require renewal based on continued clinical benefit.

Renewal Requirements

  • Response assessment via imaging (CT, MRI, or PET scans)
  • Performance status documentation
  • Toxicity evaluation and management notes
  • Treatment plan for continued therapy

Annual Plan Changes

  • Formulary updates may affect tier placement
  • Prior authorization criteria can change annually
  • Pharmacy network modifications may require switching specialty pharmacies

Planning tip: Review your plan's Annual Notice of Change (sent in October) for any Tecentriq-related modifications for the following year.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed prior authorization and appeal letters. Our platform analyzes denial letters and plan policies to craft point-by-point rebuttals aligned with each payer's specific requirements, pulling the right clinical evidence and operational details that payers expect to see.

For complex cases requiring detailed appeal strategies, Counterforce Health provides specialized support in navigating payer-specific workflows and documentation requirements.

FAQ

How long does Humana prior authorization take for Tecentriq in Pennsylvania? Standard prior authorization decisions are made within 14 calendar days. Expedited reviews for urgent cases are completed within 72 hours.

What if Tecentriq is non-formulary on my Humana plan? You can request a formulary exception with a medical necessity letter from your oncologist. Include clinical guidelines supporting Tecentriq over formulary alternatives.

Can I request an expedited appeal if my Tecentriq is denied? Yes, if your health condition requires urgent treatment. Both internal appeals and Pennsylvania's external review program offer expedited timelines for urgent cases.

Does step therapy apply to Tecentriq in Pennsylvania? Step therapy requirements vary by indication and plan. Your oncologist can request an exception if you have contraindications to preferred agents or have failed them outside Pennsylvania.

What happens if I can't afford my Tecentriq copay? Commercial insurance patients may qualify for Genentech's co-pay assistance program. Medicare patients should explore independent foundation grants and speak with their treatment team about financial assistance programs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for the most current coverage policies and medical recommendations. Coverage policies may vary by specific plan and can change annually.

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