By Counterforce Health Team in Tecentriq (atezolizumab) —

How to Get Tecentriq (Atezolizumab) Covered by Humana in New York: Forms, Appeals, and Provider Contacts

Answer Box: Getting Tecentriq (Atezolizumab) Covered by Humana in New York

Tecentriq (atezolizumab) requires prior authorization from Humana for most Medicare Advantage and commercial plans in New York. The fastest path to approval: 1) Submit a professionally administered drug PA form via the Humana Provider Portal or fax to 888-447-3430, 2) Include comprehensive oncology documentation (diagnosis, staging, prior therapies, biomarker results), and 3) Request expedited review if delay risks patient health. Standard decisions come within 72 hours; expedited within 24 hours. If denied, you have 60-65 days to appeal through Medicare's process (not New York's external review system).

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Forms and Submission Portals
  4. Fax Numbers and Provider Contacts
  5. Specialty Pharmacy Coordination
  6. Appeals Process for Humana in New York
  7. Common Denial Reasons and Solutions
  8. Financial Assistance Options
  9. FAQ
  10. Sources and Further Reading

Coverage Requirements at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for most Humana plans Humana PA Lists Humana Provider Portal
Formulary Status Typically Tier 3-4 (specialty) Drug Search Tool Humana PA Search
Step Therapy May require trying preferred alternatives first Part B Step Therapy List Humana Policy
HCPCS Code J9022 (IV atezolizumab) FDA labeling FDA Access Data
Appeal Deadline 60-65 days from denial notice Medicare regulations CMS Guidelines

Step-by-Step: Fastest Path to Approval

1. Verify Plan Type and Coverage

Who: Clinic staff
Action: Call the number on patient's Humana card to confirm whether Tecentriq is covered under Part B (medical) or Part D (pharmacy)
Timeline: 10-15 minutes

2. Gather Clinical Documentation

Who: Oncologist and clinic team
Required documents:

  • Complete cancer diagnosis with ICD-10 codes and staging
  • Prior therapy history with dates, responses, and reasons for discontinuation
  • Relevant biomarker results (PD-L1, MSI, mutation panels as applicable)
  • Performance status and treatment intent (curative vs. palliative)
  • Dosing schedule aligned with FDA labeling or NCCN guidelines

3. Complete Prior Authorization Form

Who: Provider
Form: Professionally Administered Drug PA Form
Timeline: Allow 30-45 minutes for completion

4. Submit with Expedited Request

How: Humana Provider Portal or fax to 888-447-3430
Mark as: "Expedited - Active malignancy, delay may jeopardize health"
Timeline: Submit within 24-48 hours of gathering documentation

5. Follow Up

When: 24-48 hours after submission
Action: Check portal status or call 800-486-2668 for updates

Tip: For urgent cases, call the Clinical Pharmacy Review line immediately after faxing to flag the urgency and confirm receipt.

Forms and Submission Portals

Primary Submission Methods

Humana Provider Portal (Preferred)

  • Access via Availity Essentials
  • Navigate to "Coverage & Authorizations"
  • Upload supporting clinical documents directly
  • Real-time status tracking available

Fax Submission

  • Medical PA fax: 888-447-3430 (Medication Intake Team)
  • Expedited coverage decisions: 888-200-7440
  • Include cover sheet with member ID, drug name, and "EXPEDITED" if applicable

Required Documentation Checklist

✓ Completed PA form with all sections filled
✓ Chart notes documenting diagnosis and staging
✓ Prior therapy summary with outcomes
✓ Biomarker/pathology reports
✓ Medical necessity letter from oncologist
✓ Relevant imaging or lab results
✓ Copy of patient's insurance card

Fax Numbers and Provider Contacts

Humana Prior Authorization

  • Medical PA (office-administered drugs): 888-447-3430
  • Expedited coverage decisions: 888-200-7440
  • General pharmacy PA: Use CoverMyMeds portal

CenterWell Specialty Pharmacy

  • Provider fax (prescription orders): 877-405-7940
  • Clinical support line: 800-486-2668 (Mon-Fri 8am-11pm, Sat 8am-6:30pm ET)
  • E-prescribe: Search "CenterWell Specialty Pharmacy" in your system

Appeals and Member Services

  • Part D appeals fax: 877-556-7005
  • Member services: Number on back of insurance card
  • Provider services: 800-555-2546 (Clinical Pharmacy Review)

Specialty Pharmacy Coordination

Most Humana plans require Tecentriq to be obtained through CenterWell Specialty Pharmacy for home delivery or through approved specialty pharmacy networks for office administration.

Onboarding Steps

  1. E-prescribe to CenterWell Specialty Pharmacy while PA is pending
  2. CenterWell will contact patient for benefits verification and financial assistance screening
  3. Once PA is approved, CenterWell coordinates delivery timing with infusion schedule
  4. For office administration, verify your clinic is in CenterWell's network
Note: CenterWell provides clinical support services including patient education, side effect management, and adherence monitoring at no additional cost.

Appeals Process for Humana in New York

Important: Humana Medicare Advantage members in New York use the federal Medicare appeals process, not the New York State Department of Financial Services external review system.

Level 1: Plan Appeal (Redetermination)

  • Deadline: 60 days from denial notice date
  • How to file: Humana Provider Portal, phone, or mail
  • Timeline: 7 days for standard appeals, 72 hours for expedited
  • Required: Copy of denial notice, additional clinical documentation

Level 2: Independent Review (QIC)

  • Deadline: 60 days from Level 1 denial
  • Reviewer: Qualified Independent Contractor (not Humana)
  • Timeline: Similar to Level 1 timelines

When to Request Expedited Appeals

Your oncologist should request expedited review when:

  • Patient has active, progressive malignancy
  • Delay in treatment could seriously jeopardize health
  • Standard timeline would compromise treatment outcomes

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
Off-label use Cite NCCN guidelines or peer-reviewed literature Published studies, practice guidelines
Step therapy not met Document contraindications to preferred agents Prior therapy records, allergy history
Insufficient biomarker testing Provide complete molecular profile Pathology reports, mutation analysis
Site of care restriction Justify medical necessity for specific setting Clinical rationale for outpatient vs. hospital
Experimental/investigational Reference FDA approval and standard of care FDA labeling, society guidelines

Financial Assistance Options

Manufacturer Support

  • Genentech Patient Foundation: Income-based assistance for eligible patients
  • Copay assistance: May be available for commercial plans (not Medicare)
  • Application: Available through Genentech Access Solutions (verify current programs)

New York State Resources

  • Community Health Advocates: 888-614-5400 (free insurance counseling)
  • New York State of Health: marketplace plans with potential premium assistance
  • Medicaid: Coverage for eligible low-income patients

FAQ

How long does Humana prior authorization take for Tecentriq?
Standard PA decisions are made within 72 hours; expedited requests within 24 hours. Submit requests as expedited when delay could jeopardize patient health.

What if Tecentriq is not on Humana's formulary?
File a formulary exception request with medical necessity documentation. Include evidence that preferred alternatives are inappropriate or ineffective.

Can I appeal a Humana denial through New York state?
No. Medicare Advantage members must use the federal Medicare appeals process, not New York's external review system administered by the Department of Financial Services.

What biomarker testing is required for Tecentriq approval?
Requirements vary by indication. Common requirements include PD-L1 expression, microsatellite instability (MSI), and mutation testing relevant to the specific cancer type.

Does step therapy apply if my patient tried other treatments outside New York?
Yes, prior therapies from any location count toward step therapy requirements. Provide complete documentation of previous treatments and outcomes.

What happens if Humana doesn't respond within the required timeframe?
For Medicare appeals, cases automatically advance to the next level if Humana exceeds required decision timeframes.

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Tecentriq. Our platform analyzes denial letters, identifies the specific coverage criteria, and generates targeted appeals with the right clinical evidence and payer-specific language. For patients and providers struggling with repeated denials or complex prior authorization requirements, Counterforce Health streamlines the process by automating the appeal workflow and ensuring all required documentation is properly formatted and submitted.

From our advocates: We've seen cases where initial Tecentriq denials were overturned simply by providing more comprehensive biomarker documentation and clearly linking the treatment to established guidelines. The key is often in the details—ensuring every prior therapy is documented with specific dates and outcomes, not just listed generically.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult with healthcare providers and insurance representatives for specific coverage questions. For additional help with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or visit the New York State Department of Financial Services for consumer assistance resources.

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