Download Atezolizumab (Tecentriq™)

REVIEW REQUEST FOR
Atezolizumab (Tecentriq )
Provider Data Collection Tool Based on Medical Policy DRUG.00088
Policy Last Review Date:
11/03/2016
Request Date:
/
Initial Request
Buy and bill
/
Policy Effective Date:
11/17/2016
Provider Tool Effective Date:
Subsequent Request
Individual’s Name:
Date of Birth:
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/
Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
11/17/2016
Diagnosis Code(s) (if known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Place of Service:
Home
Office
Dialysis Center
Outpatient Hospital
Ambulatory Infusion
Ambulatory Infusion Center
Other:
Drug Name/HCPCS Code (if known)
Dose to be administered:
Atezolizumab (Tecentriq )
J3590
J9999
C9483
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
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/
Duration:
Start Date For This Request:
(Weeks)
/
/
(mg)
(Other)
This Medical Policy based provider data collection tool is intended to facilitate a UM medical necessity review
request for use of atezolizumab (Tecentriq ) in the treatment of locally advanced or metastatic urothelial carcinoma
and metastatic non-small cell lung cancer (NSCLC) under specific circumstances.
Please check the following that apply to the individual.
Urothelial Carcinoma
□ Request is for the use of atezolizumab (Tecentriq ) in the treatment of locally advanced or metastatic urothelial carcinoma
(If checked, mark the following that apply to the individual)
□ Disease has progressed during or following platinum-containing chemotherapy (for example, cisplatin)
□ Disease has progressed within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy
□ Individual has a current Eastern Cooperative Oncology Group (ECOG) performance status of 0-2
□ Individual has NOT received treatment with another PD-1 agent (for example, nivolumab or pembrolizumab)
□ Individual is NOT receiving therapy for an autoimmune disease or chronic condition requiring treatment with a systemic
Immunosuppressant
REVIEW REQUEST FOR
Atezolizumab (Tecentriq )
Provider Data Collection Tool Based on Medical Policy DRUG.00088
Policy Last Review Date:
11/03/2016
Policy Effective Date:
11/17/2016
Provider Tool Effective Date:
11/17/2016
Non-Small Cell Lung Cancer (NSCLC)
□ Request is for the use of atezolizumab (Tecentriq) in the treatment of non-small cell lung cancer (NSCLC)
(If checked, mark the following that apply to the individual)
□ Disease has progressed during or following platinum-containing chemotherapy (for example, cisplatin)
□ Anaplastic lymphoma kinase (ALK) or epidermal growth factor receptor (EGFR) genomic tumor aberrations are present
□ Individual has experienced disease progression on U.S. Food and Drug Administration (FDA) approved therapy
□ Individual has a current Eastern Cooperative Oncology Group (ECOG) performance status of 0-2
□ Individual has NOT received treatment with another PD-1 agent (for example, nivolumab or pembrolizumab)
□ Individual is NOT receiving therapy for an autoimmune disease or chronic condition requiring treatment with a systemic
Immunosuppressant
Other Indication not listed above (Please submit all supporting documents including labs, progress notes, imaging, etc.,
for review.)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I confirm that the information entered on this form is accurate and complete based on the records available at the time of this
request. I understand the health plan or its designees may request medical documentation to verify the accuracy of the
information reported on this form.
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/
Name & Title of Provider or Provider Representative Completing Form
Date
& attestation (Please Print)*
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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