By Counterforce Health Team in Tecentriq (atezolizumab) —

How to Get Tecentriq (Atezolizumab) Covered by Humana in Georgia: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Tecentriq Covered by Humana in Georgia

Tecentriq (atezolizumab) requires prior authorization from Humana as a Tier 4 specialty drug. Your oncologist must submit clinical documentation including PD-L1 testing, treatment history, and medical necessity justification. If denied, you have 65 days to file an internal appeal, followed by Georgia's external review process within 60 days of the final denial. Start today: Ask your oncologist to initiate prior authorization through Humana's provider portal with all required lab results and biomarker testing.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Humana formulary Humana Medicare Advantage Drug Guide
Formulary Tier Tier 4 (specialty) Plan documents Humana Formulary
Step Therapy May apply by indication Provider policy sheet Humana Step Therapy List
Specialty Pharmacy Preferred through CenterWell Provider resources CenterWell Specialty
Appeal Deadline 65 days from denial Evidence of Coverage Humana Appeals Process

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Your oncology team
What: PD-L1 testing results, mutation analyses (EGFR/ALK if NSCLC), pathology reports, treatment history
Timeline: Before PA submission
Source: Humana Prior Authorization Guidelines

2. Submit Prior Authorization

Who: Prescribing oncologist
What: Complete PA form with clinical justification
How: Humana provider portal or fax to 1-877-486-2621
Timeline: Allow 7-14 days for standard review
Source: Humana Provider Resources

3. Review Determination

Who: Patient and provider
What: Check for approval, denial, or request for additional information
Timeline: Within 30 days for Medicare Advantage
Source: CMS Appeals Guidelines

4. File Internal Appeal (if denied)

Who: Patient or provider
What: Submit appeal with additional clinical evidence
Deadline: 65 days from denial notice
Timeline: Decision within 30 days (72 hours if expedited)
Source: Humana Appeals Process

5. Request External Review (if needed)

Who: Patient
What: Georgia Department of Insurance external review application
Deadline: 60 days from final internal denial
Timeline: 30 business days (72 hours if expedited)
Cost: Free to consumers

Understanding Your Benefit Design

What Drives Tecentriq Costs

Tecentriq's placement on Tier 4 (specialty tier) means you'll face the highest cost-sharing in your plan. With list prices around $8,113 per 840mg vial and $11,589 per 1200mg vial, understanding your benefit structure is crucial for budgeting treatment costs.

Key Cost Factors:

  • Formulary tier: Tier 4 specialty drugs typically require 25-33% coinsurance
  • Deductible: Must be met before coverage begins
  • Out-of-pocket maximum: Your annual protection limit
  • Site of care: Part B vs. Part D coverage affects cost-sharing
Tip: Medicare patients cannot use manufacturer copay cards, but independent foundations may provide assistance.

Investigating Your Coverage

Questions to Ask Humana

Call Humana member services with these specific questions:

  1. "What is my specialty drug cost-sharing for Tier 4 medications?"
  2. "Has my deductible been met for this year?"
  3. "What is my remaining out-of-pocket maximum?"
  4. "Are there quantity limits for Tecentriq?"
  5. "Which specialty pharmacies are in-network?"

Humana Member Services: 1-800-833-2364

Information to Record

  • Prior authorization reference number
  • Case manager contact (if assigned)
  • Approved dosing and frequency
  • Pharmacy restrictions
  • Next review date

Cost Assistance Options

For Commercial Insurance Patients

Genentech Co-pay Assistance Program

  • Benefit: Up to $25,000 per calendar year
  • Eligibility: Commercial insurance only (not Medicare/Medicaid)
  • Application: CopayAssistanceNow.com or call 855-692-6729
  • Requirements: Valid prescription, 18+ years old, U.S. resident

For Medicare Patients

Since Medicare patients cannot use manufacturer copay programs, consider these alternatives:

Independent Foundations:

  • Patient Advocate Foundation
  • CancerCare Co-Payment Assistance
  • Leukemia & Lymphoma Society
  • Good Days (formerly Chronic Disease Fund)

Genentech Patient Foundation

Requesting Tiering Exceptions

When to Request an Exception

Consider a formulary exception if:

  • Tecentriq is not covered (non-formulary)
  • Step therapy requirements don't align with clinical guidelines
  • Preferred alternatives have failed or are contraindicated

Evidence to Include

Clinical Documentation:

  • Medical necessity letter from oncologist
  • Treatment history showing failed alternatives
  • Peer-reviewed literature supporting use
  • NCCN guideline references
  • Contraindication documentation for preferred drugs

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by ingesting denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each plan's specific rules.

Pharmacy Choice Considerations

Specialty vs. Retail Coordination

CenterWell Specialty Pharmacy (Humana's preferred)

  • Integrated with Humana systems
  • Clinical support services
  • Coordinated prior authorizations
  • Home delivery available

Alternative Specialty Pharmacies

  • May require additional coordination
  • Verify in-network status
  • Confirm prior authorization transfers

Coordination Tips

  1. Confirm network status before first fill
  2. Transfer prescriptions properly between pharmacies
  3. Maintain consistent pharmacy for continuity
  4. Coordinate with clinic for administration timing

Appeals Process in Georgia

Internal Appeal (First Level)

Timeline: File within 65 days of denial
Decision: 30 days standard, 72 hours expedited
Required: Medical records, physician letter, denial notice

External Review (Second Level)

Georgia's external review process provides an independent assessment of Humana's denial:

Eligibility: After internal appeal denial
Deadline: 60 days from final internal denial
Cost: Free to consumers
Decision: 30 business days (72 hours if expedited)
Outcome: Binding on Humana

To Request External Review:

  • Contact Georgia Department of Insurance: 1-800-656-2298
  • Submit application with supporting documentation
  • Include all medical records and appeal correspondence
Note: Georgia allows concurrent expedited external review for urgent situations—you don't have to wait for internal appeal completion if delay poses serious health risk.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Off-label use Cite NCCN guidelines NCCN reference, clinical rationale
Missing biomarkers Submit test results PD-L1, EGFR/ALK testing reports
Step therapy Document failures Prior therapy records, intolerance notes
Not medically necessary Provide clinical justification Treatment history, disease progression
Quantity limits Request override Dosing rationale, physician letter

Counterforce Health helps patients and clinicians get prescription drugs approved by identifying denial basis and drafting targeted rebuttals with the right evidence citations and clinical facts.

Frequently Asked Questions

Q: How long does Humana prior authorization take for Tecentriq? A: Standard prior authorization decisions are made within 30 days for Medicare Advantage plans. Expedited reviews (for urgent situations) are completed within 72 hours.

Q: Can I appeal if Tecentriq is non-formulary? A: Yes, you can request a formulary exception. Your oncologist must demonstrate medical necessity and why preferred alternatives are inappropriate for your condition.

Q: What if I need Tecentriq immediately? A: Request expedited prior authorization and appeal processes. For life-threatening situations, your oncologist can request emergency coverage while the appeal is processed.

Q: Does step therapy apply to all Tecentriq indications? A: Step therapy requirements vary by specific cancer indication and line of therapy. Check Humana's current step therapy list for your diagnosis.

Q: Can I use GoodRx or discount programs with Humana? A: Medicare patients cannot combine discount programs with insurance coverage. However, you may compare cash prices if insurance coverage is denied.

Q: What happens if my appeal is denied? A: After internal appeal denial, you can request external review through the Georgia Department of Insurance within 60 days. This independent review is binding on Humana.

Q: How do I find out my exact copay for Tecentriq? A: Call Humana member services at 1-800-833-2364 with your member ID. They can provide specific cost-sharing information based on your plan and deductible status.

Q: Can my doctor request a peer-to-peer review? A: Yes, oncologists can request peer-to-peer reviews with Humana's medical directors to discuss complex cases and provide additional clinical context.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies and requirements may change—verify current information with Humana and your healthcare team before making treatment decisions.

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