By Counterforce Health Team in Tecentriq (atezolizumab) —

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

Answer Box: Getting Tecentriq Covered by Humana in Illinois

Tecentriq (atezolizumab) requires prior authorization from Humana and must be dispensed through specialty pharmacies like CenterWell. In Illinois, if denied, you have 65 days to appeal and can request an independent external review within 30 days of a final denial. First step: Have your oncologist submit a prior authorization request with complete clinical documentation, including diagnosis, prior treatments, and medical necessity justification. Commercial insurance patients may qualify for Genentech's copay assistance (up to $25,000/year), but Medicare patients need alternative financial aid.

Table of Contents

  1. What Drives Tecentriq Costs with Humana
  2. Benefit Investigation: What to Ask
  3. Prior Authorization Requirements
  4. Assistance Options for Patients
  5. Specialty Pharmacy Requirements
  6. Appeals Process in Illinois
  7. Common Denial Reasons & Solutions
  8. Annual Planning and Renewals
  9. Conversation Scripts
  10. FAQ

What Drives Tecentriq Costs with Humana

Tecentriq (atezolizumab) is a high-cost specialty oncology drug that Humana typically places on Tier 5 (Non-Preferred Specialty), the highest cost-share level. At approximately $8,113 per 840-mg vial, the annual cost can exceed $200,000 depending on your dosing regimen.

Key cost factors include:

  • Formulary tier placement (usually Tier 5)
  • Prior authorization requirements
  • Step therapy protocols (trying preferred alternatives first)
  • Specialty pharmacy dispensing (limited network)
  • Site-of-care restrictions (infusion center requirements)
Note: Humana's Medicare Advantage plans have relatively low denial rates (~3.5%) compared to other insurers, but specialty drugs like Tecentriq face stricter scrutiny due to their high cost.

Benefit Investigation: What to Ask

Before starting treatment, gather this essential information from Humana:

Questions for Humana Customer Service (1-800-457-4708):

  • Is Tecentriq on my plan's formulary?
  • What tier is it placed on, and what's my copay/coinsurance?
  • Is prior authorization required?
  • Are there step therapy requirements?
  • Which specialty pharmacies can dispense it?
  • What documentation is needed for approval?

Information to record:

  • Your member ID and group number
  • Plan year (coverage can change annually)
  • Specific formulary name
  • Prior authorization reference number (once submitted)

Prior Authorization Requirements

Tecentriq requires prior authorization for all Humana plans. Your oncologist must submit comprehensive documentation through Humana's provider portal or by fax.

Step-by-Step: Fastest Path to Approval

  1. Oncologist submits PA request with complete clinical package
  2. Include required documentation: diagnosis (ICD-10), staging, biomarker results, prior treatments
  3. Specify medical necessity: why Tecentriq is appropriate for your specific case
  4. Submit to specialty pharmacy simultaneously to avoid delays
  5. Follow up within 72 hours if no response
  6. Request expedited review if treatment delay poses health risks
  7. Prepare appeal materials in case of initial denial

Medical Necessity Documentation Checklist

Required clinical information:

  • ✓ Cancer diagnosis with ICD-10 codes
  • ✓ Disease stage and histology
  • ✓ PD-L1 expression levels (when applicable)
  • ✓ Prior treatment history and outcomes
  • ✓ Contraindications to formulary alternatives
  • ✓ Supporting guidelines (NCCN, FDA labeling)
  • ✓ Planned treatment duration and monitoring

Assistance Options for Patients

Commercial Insurance Patients

Genentech Copay Assistance Program

  • Eligibility: Commercial insurance only (no Medicare/Medicaid)
  • Benefit: Up to $25,000 per calendar year
  • How to apply: CopayAssistanceNow.com or call (855) MY-COPAY
  • Requirements: Valid prescription, U.S. residency, age 18+

Medicare/Government Insurance Patients

Since Genentech's copay program excludes Medicare patients, consider these alternatives:

Illinois-Specific Financial Assistance:

  • Illinois CancerCare Foundation: Provides assistance for Illinois cancer patients, including support for advanced therapies
  • CancerCare Co-Payment Assistance Foundation: Income up to 500% of federal poverty level
  • Patient Advocate Foundation: Small grants for qualified patients
  • CCSI Foundation: Specifically serves Illinois cancer patients
Tip: Contact your cancer center's financial counselor first—they often have relationships with local foundations and can expedite applications.

Specialty Pharmacy Requirements

Tecentriq cannot be filled at regular retail pharmacies and requires specialty pharmacy dispensing through Humana's network.

Humana's Preferred Specialty Pharmacy:

  • CenterWell Specialty Pharmacy (Humana's affiliated pharmacy)
  • Handles cold-chain shipping and clinical support
  • Coordinates with infusion centers
  • Provides patient counseling and adherence support

Process:

  1. Oncologist sends prescription to CenterWell or approved specialty pharmacy
  2. Pharmacy coordinates with your infusion center
  3. Medication ships directly to treatment facility
  4. Clinical team manages administration scheduling

For specialty pharmacy questions, call Humana Provider Services or contact CenterWell directly.

Appeals Process in Illinois

If Humana denies your Tecentriq request, Illinois provides strong patient protections with specific timelines.

Internal Appeal (First Level)

  • Timeline: 65 days from denial to file
  • Decision timeframe: 7 days (standard) or 72 hours (expedited)
  • How to file: Humana member portal, phone, or written request
  • Required: Clinical justification and supporting documentation

External Review (Independent)

  • Timeline: 30 days from final internal denial (shorter than most states)
  • Decision timeframe: 5 business days after IRO receives materials
  • Process: Independent physician reviewer with oncology expertise
  • Cost: Free to patients (Humana pays)
  • Authority: Illinois Department of Insurance

Illinois-Specific Resources

  • Illinois Department of Insurance Consumer Hotline: (877) 527-9431
  • Illinois Attorney General Health Care Helpline: (877) 305-5145
  • Both can provide guidance and intervention support

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
Step therapy not completed Document contraindications or failures of preferred agents; request medical exception
Off-label use Provide compendia support (NCCN, Lexicomp) and peer-reviewed literature
Insufficient biomarker testing Submit PD-L1 results and molecular profiling reports
Site of care restriction Justify infusion center necessity; provide facility credentials
Dosing/frequency questions Reference FDA labeling and clinical protocols
Medical necessity unclear Strengthen clinical narrative with specific patient factors

Annual Planning and Renewals

Important reminders for plan year transitions:

  • Formulary placement can change annually
  • Prior authorizations may need renewal
  • Copay assistance programs reset each calendar year
  • Step therapy requirements may be updated

Action items each January:

  • Verify Tecentriq remains on formulary
  • Confirm specialty pharmacy network
  • Renew copay assistance enrollment
  • Update insurance information with all providers

Conversation Scripts

Calling Humana Customer Service

"I'm calling about prior authorization for Tecentriq, generic name atezolizumab, for cancer treatment. My member ID is [number]. Can you tell me the current status of PA request [reference number] and what additional information might be needed?"

Requesting Expedited Review

"My oncologist has indicated that delaying this treatment could seriously jeopardize my health. I'm requesting an expedited review of this prior authorization. What's the process and timeline for urgent requests?"

Speaking with Specialty Pharmacy

"I have a prescription for Tecentriq that needs to be filled through specialty pharmacy. My insurance is Humana, and I understand you coordinate with infusion centers. What's the next step to get this processed?"

Counterforce Health helps patients navigate complex insurance approval processes for specialty medications like Tecentriq. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that align with each insurer's specific requirements. By combining clinical expertise with payer-specific workflows, we help turn insurance denials into approvals, saving patients and providers valuable time during critical treatment decisions.

FAQ

Q: How long does Humana's prior authorization process take for Tecentriq? A: Standard requests receive decisions within 72 hours of complete submission. Expedited requests are processed within 24 hours when medical urgency is documented.

Q: Can I use retail pharmacies for Tecentriq? A: No. Tecentriq is designated as "Limited Access" and must be dispensed through Humana's specialty pharmacy network, typically CenterWell Specialty Pharmacy.

Q: What if Tecentriq isn't on my Humana formulary? A: You can request a formulary exception with robust medical necessity documentation. The process follows the same 72-hour timeline as prior authorizations.

Q: Does Illinois have different appeal rights than other states? A: Yes. Illinois requires external review requests within 30 days of final denial (shorter than many states' 4-month window), but provides faster IRO decisions (5 business days).

Q: Can Medicare patients get copay assistance for Tecentriq? A: Genentech's copay program excludes all government insurance. Medicare patients should explore charitable foundations like CancerCare Co-Payment Assistance Foundation.

Q: What happens if I miss an appeal deadline? A: Missing Illinois' 30-day external review deadline can forfeit your independent review rights. Contact the Illinois Department of Insurance immediately to discuss options.

Q: How do I find an Illinois cancer financial assistance program? A: Start with your cancer center's financial counselor, then contact Illinois-specific foundations like the Illinois CancerCare Foundation or CCSI Foundation.

Q: Can my doctor request a peer-to-peer review with Humana? A: Yes. Oncologists can request to speak directly with Humana's medical director to discuss complex cases and provide additional clinical context.

This guide provides educational information about insurance coverage and is not medical advice. Coverage decisions depend on individual plan terms and clinical circumstances. For personalized guidance, consult your healthcare provider and insurance representative.

Sources & Further Reading:

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