MedicaidPrior AuthHigh impact
Atezolizumab products (Tecentriq, Tecentriq Hybreza) (Revised)
Humana·OH · Oncology, Pulmonology, Hematology·Medicaid
Effective date
Dec 1, 2025
We identified it
Aug 12, 2026
Summary
Humana Medicaid Ohio has issued a revised prior authorization policy for Tecentriq and Tecentriq Hybreza (atezolizumab products) effective December 1, 2025, with a revision date of February 1, 2026. This policy defines coverage criteria for seven cancer indications including NSCLC, small cell lung cancer, hepatocellular carcinoma, melanoma, and alveolar soft part sarcoma. All uses require prior authorization with specific clinical criteria and exclusions for prior anti-PD-1/PD-L1 therapy failure.
Action Required
By December 1, 2025: Billing team must implement prior authorization requirements in billing system for all Tecentriq (J9022) and Tecentriq Hybreza (J9023) claims for Medicaid Ohio members. Establish verification workflow to confirm: (1) diagnosis matches one of seven covered indications (NSCLC frontline/subsequent/adjuvant, small cell lung cancer, hepatocellular carcinoma, melanoma, ASPS); (2) clinical criteria are met per indication-specific requirements (genomic testing, PD-L1 status, combination therapy specifications, surgical history); (3) member has NOT experienced prior disease progression on anti-PD-1/PD-L1 therapy (Opdivo, Keytruda, Tecentriq, Bavencio). Update encounter forms and EMR templates to capture required documentation: EGFR/ALK/ROS1 testing status, PD-L1 expression levels with FDA-approved test confirmation, treatment regimen composition, prior therapy history, surgical resection date for adjuvant cases, and treatment duration tracking for adjuvant NSCLC (max 1 year). Train providers and clinical staff on new criteria. Establish tracking system for 6-month initial and renewal authorization periods. Claims submitted without prior authorization or missing clinical documentation will be denied. Coordinate with oncology and pulmonology practices regarding new documentation requirements.