By Counterforce Health Team in Tecentriq (atezolizumab) —

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

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

Tecentriq (atezolizumab) requires prior authorization from Humana Medicare Advantage plans in Texas and is subject to step therapy requirements. The fastest path to approval involves three key steps: (1) Have your oncologist call Humana at 866-461-7273 to initiate prior authorization, (2) Submit complete clinical documentation including diagnosis, staging, and prior therapy failures, and (3) If denied, file an internal appeal within 65 days followed by external review if needed. Start today by verifying your specific Humana plan's formulary status and gathering your treatment history.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Required Forms and Documentation
  3. Submission Portals and Contact Information
  4. Step-by-Step: Fastest Path to Approval
  5. Common Denial Reasons and Solutions
  6. Appeals Process for Humana in Texas
  7. Specialty Pharmacy Requirements
  8. Support Resources and Contact Information
  9. Texas Regulatory Assistance
  10. Frequently Asked Questions

Start Here: Verify Your Plan and Find Forms

Before requesting Tecentriq (atezolizumab) coverage, confirm your specific Humana plan type and formulary status. Tecentriq is listed on Humana's prior authorization requirements list under HCPCS code J9022 for all Medicare Advantage plans in Texas.

Coverage at a Glance

Requirement Status Details Source
Prior Authorization Required All Humana MA plans in Texas Humana PA List
Step Therapy Required Must try preferred alternatives first Step Therapy List
Formulary Status Varies by plan Check your specific formulary Drug Lists
Site of Care Restrictions may apply Verify approved administration sites PA Search Tool
Note: New members have a 90-day transition period where prior authorization may be waived for ongoing treatments that began before enrollment.

Required Forms and Documentation

Essential Documents for Prior Authorization

For Providers:

  • Humana Prior Authorization Form for Professionally Administered Drugs (available via Humana Provider Portal)
  • Complete medical records documenting diagnosis and staging
  • Documentation of prior therapy failures or contraindications
  • Laboratory results and imaging studies
  • Treatment plan with dosing schedule

For Patients:

  • Insurance card and member ID
  • Complete list of previously tried cancer treatments
  • Medical records from oncology visits
  • Any previous denial letters or EOBs

Medical Necessity Letter Checklist

Your oncologist's letter should include:

  • Diagnosis: Specific cancer type with ICD-10 codes
  • Staging: Current disease stage and progression status
  • Prior treatments: Detailed history of previous therapies and outcomes
  • Clinical rationale: Why Tecentriq is medically necessary
  • Contraindications: Why preferred alternatives are inappropriate
  • Dosing plan: Specific regimen (840mg q2w, 1200mg q3w, or 1680mg q4w)
  • Monitoring plan: Safety monitoring and response assessment

Submission Portals and Contact Information

Primary Contact Methods

Phone: 866-461-7273 (TTY: 711)
Hours: Monday-Friday, 8 a.m.-11 p.m. Eastern Time
Fax: 888-447-3430

Provider Portal: Humana Provider Portal

Texas-Specific Provider Support

For region-specific assistance, Texas providers can contact:

General Provider Line: 800-448-6262
Case Management: 800-523-0023 (24/7)

Step-by-Step: Fastest Path to Approval

1. Verify Coverage Requirements

Who: Patient or clinic staff
Action: Check your specific plan's formulary and PA requirements
Timeline: Same day
Link: Humana Drug Lists

2. Gather Clinical Documentation

Who: Oncology team
Action: Compile diagnosis, staging, prior treatments, and lab results
Timeline: 1-2 business days
Required: Complete treatment history and medical necessity justification

3. Submit Prior Authorization Request

Who: Prescribing physician or authorized staff
Action: Submit PA form with supporting documentation
Timeline: Submit 5-7 days before planned treatment
Contact: 866-461-7273 or fax 888-447-3430

4. Follow Up on Status

Who: Clinic staff
Action: Track PA status and respond to any requests for additional information
Timeline: Check within 2-3 business days
Portal: Humana Provider Portal

5. Handle Step Therapy Requirements

Who: Oncologist
Action: Document medical reasons why preferred alternatives are inappropriate
Timeline: May add 1-2 days to approval process
Documentation: Clinical contraindications or prior failures

6. Coordinate with Specialty Pharmacy

Who: Patient and clinic
Action: Set up delivery and administration logistics
Timeline: 2-3 business days after approval
Contact: CenterWell Specialty Pharmacy

7. Prepare for Treatment

Who: Patient
Action: Confirm insurance authorization before first infusion
Timeline: Day of treatment
Verification: Ensure PA approval is active in system

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Step therapy not completed Document contraindications to preferred drugs Prior therapy failures, adverse reactions, medical contraindications
Insufficient medical necessity Strengthen clinical justification Updated staging, progression documentation, treatment guidelines
Missing biomarker testing Submit required test results PD-L1 expression, mutation testing as indicated
Site of care restrictions Verify approved administration locations Facility credentials, safety protocols
Dosing/frequency issues Align with FDA-approved regimens Clinical rationale for specific dosing schedule
Tip: Most denials can be overturned with additional clinical documentation. Work closely with your oncology team to address specific concerns raised in the denial letter.

Appeals Process for Humana in Texas

Internal Appeals (First Level)

Timeline: Must file within 65 days of denial notice
Process: Submit written appeal with additional supporting documentation
Contact: Use same submission methods as initial PA request
Response Time: 30 days for standard, 72 hours for expedited

External Review (Independent Review Organization)

If Humana upholds the denial, you can request external review:

Federal External Review: 1-888-866-6205 (Maximus Federal)
Timeline: Request within 65 days of final internal denial
Process: Independent medical reviewers evaluate the case
Decision: Binding on Humana if overturned

Texas-Specific Appeal Rights

While Humana Medicare Advantage follows federal appeal processes, Texas residents have additional protections:

  • Right to expedited appeals for urgent situations
  • Access to Texas Department of Insurance complaint process
  • Consumer assistance through TDI hotline: 1-800-252-3439

Specialty Pharmacy Requirements

Tecentriq requires coordination with CenterWell Specialty Pharmacy, Humana's specialty pharmacy partner.

Setup Process

  1. Enrollment: Your oncologist submits prescription to CenterWell
  2. Benefits verification: CenterWell confirms PA approval and coverage
  3. Delivery coordination: Medication shipped to infusion center
  4. Administration: Treatment given at approved facility

Contact Information:

  • Phone: 1-800-486-2668
  • Fax: 1-877-405-7940
  • E-prescribe: Available through provider portal
Note: CenterWell also offers patient assistance programs and copay support. Ask about financial assistance options when setting up your prescription.

Support Resources and Contact Information

Patient Support

  • Humana Member Services: Number on your member ID card
  • CenterWell Specialty Pharmacy: 1-800-486-2668
  • Genentech Patient Foundation: Financial assistance for eligible patients

Provider Support

  • Prior Authorization: 866-488-5995
  • Case Management: 800-523-0023
  • Provider Services: 800-448-6262

Clinical Resources

When preparing your medical necessity case, consider referencing:

Texas Regulatory Assistance

If you encounter problems with Humana's coverage decisions, Texas provides several avenues for assistance:

Texas Department of Insurance (TDI)

Office of Public Insurance Counsel (OPIC)

  • Help Line: 1-877-611-6742
  • Services: Consumer advocacy and appeals assistance

Independent Review Organization (IRO)

  • Information Line: 1-866-554-4926
  • Process: External medical review for denied treatments
Important: For Humana Medicare Advantage, federal appeal processes take precedence, but TDI can still provide guidance and investigate complaints about plan administration.

Frequently Asked Questions

Q: How long does Humana take to approve Tecentriq prior authorization in Texas?
A: Standard PA requests receive decisions within 72 hours. Expedited requests (for urgent medical situations) are decided within 24 hours.

Q: What if Tecentriq isn't on my Humana formulary?
A: You can request a formulary exception through the coverage determination process. Your oncologist must demonstrate medical necessity and why covered alternatives are inappropriate.

Q: Can I get expedited appeals for cancer treatment?
A: Yes, if waiting for standard appeal timelines would seriously jeopardize your health, you can request expedited review at both internal and external appeal levels.

Q: Does step therapy apply if I've already failed other treatments?
A: Document all prior therapy failures thoroughly. If you've tried and failed preferred alternatives, this should satisfy step therapy requirements.

Q: What happens if my external review is successful?
A: External review decisions are binding. If the independent reviewers overturn Humana's denial, the plan must cover your Tecentriq treatment.

Q: Are there financial assistance options for Tecentriq?
A: Yes, Genentech offers patient assistance programs, and CenterWell Specialty Pharmacy can help identify copay support options and foundation grants.

Counterforce Health helps patients and clinicians navigate complex insurance approval processes by turning denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create compelling medical necessity cases that align with each insurer's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly for coverage determinations. For additional assistance with insurance appeals in Texas, contact the Texas Department of Insurance at 1-800-252-3439 or visit www.tdi.texas.gov.

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