By Counterforce Health Team in Tecentriq (atezolizumab) —

How to Get Tecentriq (Atezolizumab) Covered by Humana in New Jersey: Prior Authorization, Appeals, and Financial Assistance

Answer Box: Getting Tecentriq Covered by Humana in New Jersey

Tecentriq (atezolizumab) requires prior authorization from Humana and is typically placed on Tier 3 or 4 specialty formulary tiers. Your oncologist must submit a PA request demonstrating medical necessity, often including documentation of failed preferred alternatives due to step therapy requirements. If denied, you have 65 days to appeal internally, followed by New Jersey's Independent Health Care Appeals Program (IHCAP) for external review.

First step today: Have your oncologist call Humana Clinical Pharmacy Review at 800-555-2546 to initiate the PA process while gathering your diagnosis, staging, prior treatment records, and biomarker testing results.

Table of Contents

  1. Understanding Humana's Coverage Requirements
  2. Prior Authorization Process
  3. Common Denial Reasons and Solutions
  4. Appeals Process in New Jersey
  5. Financial Assistance Options
  6. Specialty Pharmacy Requirements
  7. Clinician Documentation Guide
  8. FAQ

Understanding Humana's Coverage Requirements

Tecentriq (atezolizumab) faces several coverage hurdles with Humana Medicare Advantage plans in New Jersey. The drug is classified as nonpreferred in Humana's 2026 Part B step therapy preferred drug lists, requiring step therapy through preferred alternatives before approval.

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Mandatory approval before treatment Humana PA Search Tool 5-7 days before treatment
Step Therapy Must try preferred alternatives first Part B preferred drug list Document failures/contraindications
Formulary Tier Tier 3-4 specialty placement Plan-specific formulary Higher copays/coinsurance
Medical Necessity Clinical justification required Coverage policy criteria Ongoing documentation

Cost Impact: As a Tier 3-4 specialty drug, Tecentriq typically carries higher out-of-pocket costs. With list prices around $8,113 per 840mg vial and $11,589 per 1200mg vial, patient responsibility can be substantial even with insurance coverage.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic Staff)
    • Check specific plan formulary via Humana Drug Lists
    • Confirm PA requirements for your plan
    • Timeline: Same day
  2. Gather Required Documentation (Clinic Staff)
    • ICD-10 diagnosis codes with staging
    • Prior therapy failures/contraindications
    • Biomarker testing (PD-L1, mutations as indicated)
    • Treatment plan with specific dosing
    • Timeline: 1-2 days
  3. Submit PA Request (Oncologist)
  4. Follow Up (Clinic Staff)
    • Track via Humana Provider Portal within 2-3 days
    • Prepare for potential peer-to-peer review
    • Timeline: 72 hours for standard decision
  5. Appeal if Denied (Patient/Clinic)
    • Internal appeal within 65 days
    • Request expedited review for urgent cases
    • Timeline: 24 hours expedited, 30 days standard
Tip: For urgent cancer cases, always request expedited review. Humana must respond within 24 hours if delay would jeopardize health.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Step Therapy Not Met Document preferred drug failures/contraindications Prior treatment records, adverse event notes, allergy documentation
Off-Label Use Provide evidence-based rationale FDA prescribing information, peer-reviewed studies, NCCN guidelines
Lack of Biomarker Testing Submit required testing results PD-L1 expression, MSI status, mutation panels as indicated
Insufficient Medical Necessity Strengthen clinical justification Detailed treatment history, staging, performance status, prognosis

Counterforce Health specializes in turning these denials into targeted appeals by analyzing the specific denial basis and crafting evidence-backed rebuttals aligned to each plan's own coverage criteria.

Appeals Process in New Jersey

New Jersey offers robust appeal rights through a two-tier internal process followed by external review.

Internal Appeals with Humana

Level 1 Appeal

  • Deadline: 65 days from denial notice
  • Timeline: 30 days standard, 72 hours expedited
  • How to Submit: Online portal, phone, or mail
  • Required: Copy of denial letter, medical records, physician statement

Level 2 Appeal

  • Automatic: If Level 1 denied
  • Timeline: 30 days for decision
  • Review: Independent medical reviewers

New Jersey External Review (IHCAP)

If Humana denies your internal appeals, New Jersey's Independent Health Care Appeals Program provides independent review.

Key Details:

  • Deadline: 4 months (180 days) from final internal denial
  • Cost: Free to patients
  • Process: Submit directly to Maximus Federal Services (contracted review organization)
  • Timeline: 5 business days for acceptance, 45 days for decision
  • Contact: IHCAP Hotline: 1-888-393-1062
Note: New Jersey's external review has a strong track record. About half of external appeals nationwide favor consumers, and New Jersey's process ensures medical experts—not insurance administrators—make the final coverage determination.

Appeals Playbook Script: "I'm requesting an expedited internal appeal for the denial of Tecentriq (atezolizumab) for my [cancer type]. This is an urgent oncology case where delay could compromise my treatment outcomes. Please provide the appeal reference number and confirm the 24-hour expedited timeline."

Financial Assistance Options

Manufacturer Programs

Genentech Oncology Co-pay Assistance Program

  • Eligibility: Commercial insurance only (Medicare patients ineligible)
  • Benefit: Up to $25,000 per calendar year
  • Apply: TECENTRIQ Access Solutions: (877) 436-3683
  • Requirements: FDA-approved use, US resident, commercial coverage

Genentech Patient Foundation

  • Eligibility: Uninsured/underinsured, income up to 500% Federal Poverty Level (~$75,300 for household of 2)
  • Coverage: Full medication cost
  • Apply: GenentechPatientFoundation.com

National Foundations

  • HealthWell Foundation: Cancer-specific funds, 400-500% FPL income limit
  • Patient Advocate Foundation: Case management and copay assistance
  • The Assistance Fund: Drug-specific copay support
  • CancerCare: Transportation, childcare, limited copay help

New Jersey-Specific Resources

Organization Coverage Eligibility Contact
David's Dream & Believe Cancer Foundation General financial aid for NJ families Cancer diagnosis, needs-based davidsdreamandbelieve.org
CancerCare Financial Assistance Transportation/childcare for NJ patients Active treatment, income guidelines 800-813-HOPE
Rutgers Cancer Institute ACS Grants Transportation/lodging grants NJ patients, distance barriers Contact social worker
American Cancer Society NJ Road to Recovery transport, $200 grants Active treatment, income guidelines cancer.org/new-jersey

Specialty Pharmacy Requirements

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

Mail Order vs. Retail Specialty

  • Transition Supply: 30-day supply for first 90 days of plan year without PA
  • Network Verification: Use Humana Pharmacy Finder or call 800-457-4708
  • PA Requirements: Must be approved before dispensing beyond transition period

Clinician Documentation Guide

Medical Necessity Letter Checklist

When submitting a PA request or appeal, include these elements:

Patient Information:

  • Complete diagnosis with ICD-10 codes
  • Cancer staging and histology
  • Performance status (ECOG/Karnofsky)
  • Relevant biomarkers (PD-L1, MSI, mutations)

Treatment History:

  • Prior therapies attempted
  • Reasons for discontinuation (progression, toxicity, contraindications)
  • Dates and duration of treatments

Clinical Rationale:

  • Why Tecentriq is medically necessary
  • Evidence supporting use in this indication
  • Expected benefits and treatment goals
  • Monitoring plan

Supporting Evidence:

  • FDA prescribing information
  • NCCN guidelines (where applicable)
  • Peer-reviewed studies for off-label use
  • Professional society recommendations

When appeals are needed, Counterforce Health helps clinicians craft targeted rebuttals by analyzing denial letters against plan policies and pulling the right evidence citations to strengthen medical necessity arguments.

FAQ

How long does Humana PA take in New Jersey? Standard PA decisions take up to 72 hours. Expedited reviews for urgent cases must be completed within 24 hours.

What if Tecentriq is non-formulary on my plan? Request a formulary exception through Humana Clinical Pharmacy Review (800-555-2546). Your prescriber must provide written justification for medical necessity.

Can I request an expedited appeal? Yes, for urgent oncology cases where delay could jeopardize health. Humana must respond within 24 hours for expedited appeals.

Does step therapy apply if I've failed therapies outside New Jersey? Yes, document all prior failures regardless of where treatment occurred. Include medical records and provider notes detailing reasons for discontinuation.

What happens if my income is too high for patient assistance? Explore Humana's transition supply policy, formulary exceptions, or tier reduction requests. Some foundations have higher income thresholds or emergency assistance programs.

How do I track my appeal status? Use Humana's member portal or call member services. For external appeals in New Jersey, contact the IHCAP hotline at 1-888-393-1062.

Can my doctor file appeals on my behalf? Yes, New Jersey allows providers to file external appeals with patient consent. Your oncology team can handle most of the process.

What if I need Tecentriq immediately? Request expedited PA review and consider Genentech's patient assistance programs for immediate access while appeals are pending.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may vary by plan and change over time. Always verify current requirements with your insurance plan and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals and prior authorizations, consider consulting with coverage specialists who can help navigate your specific situation.

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