By Counterforce Health Team in Tecentriq (atezolizumab) —

How to Get Tecentriq (Atezolizumab) Covered by Aetna CVS Health in Illinois: Forms, Appeals, and Expert Tips

Quick Answer: Getting Tecentriq Covered by Aetna CVS Health in Illinois

Tecentriq (atezolizumab) requires prior authorization from Aetna CVS Health. Your fastest path to approval: 1) Verify your plan covers specialty oncology drugs through CVS Specialty at 1-800-323-2445, 2) Submit complete biomarker testing (PD-L1, EGFR, ALK as applicable) with your PA request, and 3) Document any prior immunotherapy failures or contraindications. If denied, you have 60 days to appeal internally, then 4 months for Illinois external review. Start by calling Aetna Member Services (number on your ID card) to confirm your specific formulary status and PA requirements.

Table of Contents

  1. Start Here: Verify Your Plan Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Contact Information
  4. Appeals Playbook for Illinois Patients
  5. Common Denial Reasons and How to Fix Them
  6. Specialty Pharmacy Setup with CVS
  7. Illinois Consumer Protection Resources
  8. Frequently Asked Questions

Start Here: Verify Your Plan Coverage

Before diving into paperwork, confirm these basics with your Aetna plan:

Call Aetna Member Services (number on your ID card) and ask:

  • "Is Tecentriq (atezolizumab) covered under my plan's specialty drug benefit?"
  • "What tier is it on the formulary, and do I need prior authorization?"
  • "Are there step therapy requirements I need to meet first?"
  • "What's my specialty drug copay or coinsurance?"

Most Aetna plans route specialty oncology drugs through CVS Specialty Pharmacy. You can also contact CVS Specialty directly at 1-800-323-2445 to verify coverage.

Note: Illinois Aetna members can also call the State of Illinois Aetna line at 1-855-339-9731 (TTY: 711), available Monday–Friday, 7 AM–5 PM CT.

Prior Authorization Forms and Requirements

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for most plans Aetna Provider Portal
Biomarker Testing PD-L1, EGFR, ALK status required Your oncology team's pathology reports
Step Therapy May need to try preferred alternatives first Aetna formulary policy (verify current version)
Site of Care Infusion center requirements may apply CVS Specialty coordination
Appeal Deadline 60 days from denial notice Aetna Appeals Process

Medical Necessity Documentation

Your oncologist needs to provide:

Clinical Information:

  • Complete diagnosis with ICD-10 codes
  • Disease staging and current status
  • Prior treatment history with specific outcomes
  • Documented contraindications to preferred alternatives
  • Current performance status and treatment goals

Laboratory Evidence:

  • PD-L1 expression testing results
  • Biomarker panels (EGFR, ALK, ROS1 as applicable to indication)
  • Recent imaging showing disease progression or response
  • Liver function tests (for hepatocellular carcinoma indications)

Treatment Rationale:

  • Why Tecentriq is medically necessary over formulary alternatives
  • Evidence from FDA labeling or clinical guidelines
  • Dosing plan (840mg every 2 weeks, 1200mg every 3 weeks, or 1680mg every 4 weeks)

Submission Portals and Contact Information

For Providers

CVS Caremark Prior Authorization:

  • Fax: 1-855-633-7673
  • Phone: 1-800-552-8159
  • ePrescribing: NCPDP ID 1466033

CVS Specialty Pharmacy (Illinois Location):

  • Address: 800 Biermann Court, Mount Prospect, IL 60056
  • Phone: 1-800-323-2445
  • Fax: 1-800-323-2445

For Patients

Aetna Member Services: Use the number on your member ID card, or:

  • Illinois Medicaid (Aetna Better Health): 1-866-329-4701 (TTY: 711)
  • State of Illinois Aetna: 1-855-339-9731 (TTY: 711)

Case Management Support: For complex cases, call 1-866-600-2139 (TTY: 711) and request Case Management services.

Appeals Playbook for Illinois Patients

Internal Appeal Process

If your initial PA request is denied, you have 60 days from the denial notice to file an internal appeal with Aetna.

Standard Appeal Timeline:

  • File within: 60 days of denial
  • Aetna decision time: 30 days for standard appeals
  • Expedited appeals: 72 hours (if delay would jeopardize health)

How to File:

  1. Call Aetna Member Services and request an appeal form
  2. Submit additional medical documentation addressing denial reasons
  3. Request peer-to-peer review with an oncologist
  4. Include a letter from your doctor explaining medical necessity

Illinois External Review

After internal appeal denial, Illinois law gives you strong additional rights:

Filing Deadline: 4 months from your final internal appeal denial (shorter than many states—don't delay!)

Process:

  • Contact the Illinois Department of Insurance
  • Independent physician reviewer with oncology expertise reviews your case
  • Decision timeline: 45 days standard, 72 hours expedited
  • Cost: Free to patients
  • Binding: If approved, Aetna must cover the treatment

Illinois Consumer Support:

  • Illinois Department of Insurance: 1-877-527-9431
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145

When patients and clinicians work with specialized coverage advocates like Counterforce Health, they often see higher success rates in complex specialty drug appeals. These services help translate clinical information into the specific language and evidence that payers require, potentially saving months of back-and-forth.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Documentation Needed
"Not medically necessary" Provide FDA indication match and clinical guidelines Pathology report, staging, treatment history
"Experimental/investigational" Cite FDA approval and standard-of-care evidence FDA label, NCCN guidelines, peer-reviewed studies
Step therapy not met Document prior failures or contraindications Pharmacy records, allergy documentation, toxicity reports
Off-label use Provide compendia support and clinical rationale Drug compendia citations, medical literature
Quantity/dosing limits Justify weight-based or indication-specific dosing BSA calculations, dosing rationale from prescriber

Clinician Corner: Medical Necessity Letter Checklist

When writing your medical necessity letter, include:

Patient-Specific Factors:

  • Exact diagnosis with ICD-10 codes
  • Disease stage and molecular profile
  • Prior treatments attempted with dates and outcomes
  • Contraindications to preferred alternatives
  • Current performance status and prognosis

Treatment Rationale:

  • FDA-approved indication match
  • Dosing plan with frequency justification
  • Monitoring plan for efficacy and toxicity
  • Treatment goals and expected outcomes

Evidence Base:

  • FDA prescribing information citations
  • Relevant clinical trial data
  • Professional society guidelines (NCCN, ASCO)
  • Peer-reviewed literature supporting use

Specialty Pharmacy Setup with CVS

Once approved, Tecentriq will likely be dispensed through CVS Specialty:

Enrollment Process

  1. Prescription Transfer: Your oncologist sends the prescription to CVS Specialty (NCPDP 1466033)
  2. Benefits Verification: CVS verifies coverage and copay assistance eligibility
  3. Prior Authorization: CVS coordinates PA if not already completed
  4. Delivery Coordination: CVS ships to your infusion center or coordinates pickup

Patient Support Services

  • Copay assistance: Genentech offers patient support programs (verify eligibility)
  • Clinical support: CVS pharmacists available for questions
  • Refill coordination: Automatic refill scheduling aligned with treatment cycles
Tip: Ask CVS Specialty about Genentech's patient assistance programs, which may help with out-of-pocket costs for eligible patients.

Illinois Consumer Protection Resources

Illinois provides robust patient protection for insurance denials:

State Resources

  • Illinois Department of Insurance Office of Consumer Health Insurance (OCHI): 1-877-527-9431
  • Illinois Attorney General Health Care Bureau: 1-877-305-5145
  • External Review Program: File online or call IDOI

Timeline Protections

  • Internal appeals: Aetna must decide within 15 business days for pre-service requests
  • Expedited internal appeals: 24 hours for urgent situations
  • External review: 5 business days once all materials are submitted
  • Expedited external: 24-72 hours for urgent cases
  • Citizen Action/Illinois: May assist with complex cases
  • Local legal aid societies: Can help navigate appeals for low-income patients
  • Counterforce Health: Specialized coverage advocacy for complex drug appeals

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Tecentriq in Illinois? Standard PA decisions typically take 30-45 days, but expedited reviews (when medically urgent) can be completed within 72 hours. Your oncologist can request expedited review if treatment delays would jeopardize your health.

What if Tecentriq is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating that preferred alternatives are clinically inappropriate. Provide documentation of contraindications or prior failures with formulary drugs.

Does step therapy apply if I've failed immunotherapy in another state? Yes, documented treatment failures from other states count toward fulfilling step therapy requirements. Ensure your oncologist has complete treatment records from prior care.

Can I appeal if my doctor thinks the denial is wrong? Absolutely. Illinois law guarantees your right to internal appeals and independent external review. Your doctor's clinical opinion carries significant weight in the appeals process.

What's the cost of Tecentriq without insurance? List prices range from approximately $8,113 per 840-mg vial to $11,589 per 1200-mg vial. However, most patients should not pay these amounts—work with CVS Specialty and Genentech patient programs to explore assistance options.

How do I know if my appeal is progressing? Aetna must acknowledge receipt of your appeal and provide status updates. If you don't hear back within required timeframes, contact the Illinois Department of Insurance for assistance.

What happens if external review approves my case? The external review decision is binding—Aetna must cover your Tecentriq treatment. This typically happens within days of the favorable decision.

Can I get help with the appeals process? Yes, Illinois offers free consumer assistance through IDOI and the Attorney General's office. Some patients also work with specialized coverage advocates who understand the technical requirements of drug appeals.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with your insurer and consult your healthcare team for medical decisions.

Sources & Further Reading:

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