By Counterforce Health Team in Tecentriq (atezolizumab) —

How to Get Tecentriq (Atezolizumab) Covered by Aetna in Ohio: Prior Authorization Forms, Appeals, and Timeline

Answer Box: Getting Tecentriq Covered by Aetna in Ohio

Aetna requires prior authorization for Tecentriq (atezolizumab) in Ohio. The fastest path to approval involves submitting the complete Tecentriq Precertification Form with FDA-approved indication documentation, PD-L1 testing results (when required), and evidence of EGFR/ALK mutation status for lung cancer cases.

First step today: Have your oncologist gather your pathology report, biomarker testing, and treatment history. Call Aetna at 1-866-752-7021 to confirm your specific plan's requirements. If denied, Ohio offers external review through independent medical experts within 180 days.

Table of Contents

  1. Aetna Plan Types & Coverage Implications
  2. Tecentriq Formulary Status & Tier Placement
  3. Prior Authorization & Step Therapy Requirements
  4. Specialty Pharmacy & CVS Caremark Network
  5. Cost-Share Basics for Specialty Drugs
  6. Submission Process & Required Forms
  7. Common Approval Patterns
  8. Appeals Process in Ohio
  9. Cost Assistance Options
  10. FAQ

Aetna Plan Types & Coverage Implications

Your specific Aetna plan type affects how Tecentriq coverage works:

  • Commercial PPO/HMO Plans: Require prior authorization through CVS Caremark specialty pharmacy network
  • Medicare Advantage: May have different formulary placement; Medicare-specific forms required
  • Medicaid (Aetna Better Health Ohio): State Medicaid rules may apply alongside Aetna policies
  • Employer Self-Funded Plans: Follow Aetna guidelines but may have custom formularies
Tip: Check your insurance card for "CVS Caremark" or call the number on your card to confirm which prior authorization pathway applies to your specific plan.

Tecentriq Formulary Status & Tier Placement

Current Status: Tecentriq is generally placed on a non-preferred specialty tier (Tier 3 or 4) across most Aetna plans, meaning higher out-of-pocket costs compared to preferred alternatives.

Coverage Requirements by Indication

Indication Key Requirements PD-L1 Testing EGFR/ALK Testing
NSCLC (adjuvant) PD-L1 ≥1% after surgery + chemo Required Required
NSCLC (1st-line mono) PD-L1 ≥50% tumor cells or ≥10% immune cells Required Required
NSCLC + bevacizumab Non-squamous, no EGFR/ALK mutations Not required Required
HCC + bevacizumab Child-Pugh A, ECOG 0-1 Not required Not applicable

Source: Aetna Medical Policy

Prior Authorization & Step Therapy Requirements

All Aetna plans require prior authorization for Tecentriq. For NSCLC, Tecentriq is considered non-preferred, triggering step therapy requirements unless medically contraindicated.

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Pathology report confirming diagnosis
    • PD-L1 testing results (FDA-approved test)
    • EGFR/ALK mutation status
    • Prior treatment history and outcomes
    • Current staging and performance status
  2. Complete Precertification Form (Prescriber)
  3. Submit Request (Clinic Staff)
    • Fax: 1-888-267-3277
    • Phone: 1-866-752-7021
    • Online: Availity portal for participating providers
    • Expected timeline: 24-48 hours for standard review
  4. Follow Up (Patient/Clinic)
    • Track submission confirmation
    • Prepare for potential peer-to-peer review
    • Document any additional requests from Aetna

Specialty Pharmacy & CVS Caremark Network

Tecentriq must be filled through Aetna's specialty pharmacy network, typically CVS Specialty or an approved partner.

Setup Process:

  • Your oncologist will coordinate with CVS Specialty once prior authorization is approved
  • CVS Specialty handles insurance verification, copay assistance enrollment, and delivery coordination
  • Infusions typically occur at your oncology clinic or approved infusion center
Note: Using an out-of-network specialty pharmacy may result in no coverage or significantly higher costs.

Cost-Share Basics for Specialty Drugs

Tecentriq costs vary significantly based on your plan structure:

  • Deductible: May apply before copay/coinsurance kicks in
  • Specialty Tier Copay: Often $100-$500+ per month or 20-40% coinsurance
  • Out-of-Pocket Maximum: Provides annual cost protection

This is educational information only. Consult your plan documents or member services for specific cost details.

Submission Process & Required Forms

Medical Necessity Documentation Checklist

Clinical Information Required:

  • ✓ Histologically confirmed diagnosis with staging
  • ✓ ECOG performance status
  • ✓ Prior systemic therapies (names, dates, outcomes)
  • ✓ Contraindications to preferred alternatives
  • ✓ Treatment goals and monitoring plan

Laboratory/Pathology Requirements:

  • ✓ PD-L1 expression level (when applicable)
  • ✓ EGFR mutation status
  • ✓ ALK rearrangement status
  • ✓ Recent imaging demonstrating disease status
  • ✓ Adequate organ function labs

Common Approval Patterns

Successful submissions typically include:

  1. Clear FDA indication match - Exact alignment with approved uses
  2. Complete biomarker profile - All required testing documented
  3. Prior therapy documentation - Detailed history of treatments tried
  4. Clinical rationale - Why Tecentriq is medically necessary
  5. Contraindication evidence - If step therapy exceptions needed
From our advocates: We've seen the strongest approvals when oncologists include a brief paragraph explaining why the patient's specific tumor characteristics and treatment history make Tecentriq the most appropriate choice, referencing NCCN guidelines where applicable. This clinical narrative often makes the difference in borderline cases.

Appeals Process in Ohio

If your initial request is denied, Ohio provides robust appeal rights:

Internal Appeals with Aetna

  • Timeline: Must be filed within 180 days of denial
  • Process: Call member services or submit written appeal
  • Expected response: 30 days for standard, 72 hours for urgent

Ohio External Review Process

Ohio residents have access to independent medical review through the Ohio Department of Insurance:

Step Timeline Action Required
File Request Within 180 days of final denial Submit through Aetna or directly to ODI
IRO Assignment 5 business days ODI assigns independent reviewer
Medical Review 30 days standard / 72 hours urgent IRO reviews all medical evidence
Final Decision Binding on Aetna Coverage required if overturned

Contact Ohio Department of Insurance: 1-800-686-1526

Cost Assistance Options

Manufacturer Support

  • Genentech Patient Foundation: Need-based assistance for eligible patients
  • Tecentriq Co-pay Program: May reduce out-of-pocket costs for commercially insured patients
  • Visit Genentech Access Solutions for current programs

Additional Resources

  • CancerCare: Free financial assistance and counseling
  • Patient Access Network Foundation: Disease-specific grants
  • Ohio cancer support organizations: Local assistance programs

When patients face coverage challenges, Counterforce Health helps transform insurance denials into targeted, evidence-backed appeals by analyzing the specific denial reason and crafting point-by-point rebuttals aligned to the plan's own rules, significantly improving approval rates for complex specialty medications like Tecentriq.

FAQ

How long does Aetna prior authorization take for Tecentriq in Ohio? Standard requests receive decisions within 24-48 hours. Urgent requests (when delay would jeopardize health) are processed within 72 hours.

What if Tecentriq is non-formulary on my Aetna plan? You can request a formulary exception by providing medical necessity documentation showing why covered alternatives are inappropriate or ineffective.

Can I request an expedited appeal in Ohio? Yes, if your physician certifies that delay would seriously jeopardize your health. Both Aetna internal appeals and Ohio external reviews offer expedited timelines.

Does step therapy apply if I failed treatments outside Ohio? Yes, documented treatment failures from other states count toward step therapy requirements. Ensure your new Ohio oncologist has complete treatment records.

What happens if the Ohio external review denies coverage? The IRO decision is binding, but you retain rights to file complaints with Ohio insurance regulators or pursue other legal remedies if appropriate.

How much does Tecentriq cost without insurance coverage? List prices range from approximately $8,113 per 840mg vial to $11,589 per 1200mg vial, with total monthly costs varying by dosing schedule and indication.

When to Escalate

Contact the Ohio Department of Insurance at 1-800-686-1526 if:

  • Aetna delays responses beyond required timeframes
  • You're incorrectly told external review isn't available
  • There are procedural violations in the appeals process

For complex coverage challenges, specialized platforms like Counterforce Health can help patients and providers navigate the appeals process more effectively by identifying specific denial patterns and crafting targeted responses.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements change frequently. Always verify current requirements with your insurance plan and consult with your healthcare provider for medical decisions. For official guidance on Ohio insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526.

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