Medicare AdvantagePrior AuthHigh impact
Atezolizumab products (Tecentriq, Tecentriq Hybreza) (Revised)
Humana·FL, KY, SC · Oncology, Pulmonology, Hematology·Medicaid
Effective date
Jan 1, 2025
We identified it
Aug 12, 2026
Summary
Humana has revised its Atezolizumab (Tecentriq, Tecentriq Hybreza) pharmacy coverage policy effective January 1, 2025, expanding the line of business to include Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. The policy maintains prior authorization requirements across eight cancer indications with specific clinical criteria, including new genomic testing requirements, combination therapy specifications, and treatment duration limitations. Billing teams must verify member eligibility by plan type and state, ensure prior authorization is obtained before claims submission, and confirm all clinical criteria documentation is complete.
Action Required
IMMEDIATE (Policy effective 2025-01-01): Billing and clinical staff must implement the following: (1) Update billing system to require prior authorization for all Tecentriq (J9023) and Tecentriq Hybreza (J9024) claims for Medicare Advantage, Medicaid-FL, Medicaid-KY, and Medicaid-SC members. (2) Providers must document specific clinical criteria before submission: for NSCLC advanced/metastatic frontline—EGFR/ALK mutation status, PD-L1 expression results (≥50% if monotherapy), histology type, and intended combination regimen; for bladder cancer—muscle invasive stage, circulating tumor DNA results post-cystectomy; for NSCLC adjuvant—Stage II-IIIA diagnosis, PD-L1 ≥1%, post-resection status, chemotherapy completion, and duration not exceeding 12 months; for other indications—refer to specific criteria in policy. (3) Front desk/authorization team must verify member state of residence and plan type BEFORE processing; out-of-state or non-covered plan requests should be denied or escalated. (4) Prior authorization must be obtained and approved before drug is dispensed or claim will be denied. (5) For all indications, claims will be automatically denied if member has documented prior disease progression on anti-PD-1/PD-L1 therapy (Opdivo, Keytruda, Tecentriq, Bavencio). (6) Approvals are limited to 6-month periods; renewal requests required before continuation. Contact Humana at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a5a1316 for current policy verification.