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Tecentriq (atezolizumab) Medication Precertification Request Form
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This document is Aetna's precertification request form that providers must complete to request authorization for Tecentriq (atezolizumab) initiation or continuation of therapy for insured members. It applies to providers submitting precertification for Tecentriq infusions or dispensing.
No material clinical or coverage changes in this revision.
Coverage Criteria and Clinical Requirements
Clinical information required for authorization
Form requests clinical data that Aetna will use to determine medical necessity; the form structures criteria by indication, prior therapies, biomarker status, regimen, and toxicity.
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The precertification form asks providers to indicate when Tecentriq is being used in specific, limited clinical settings rather than providing an unconditional exclusion list. Examples of settings queried on the form include small cell neuroendocrine carcinoma of the cervix (NECC), specific mesothelioma subtypes, and tumor-specific combinations (e.g., use with etoposide + cisplatin or carboplatin). Providers must check the appropriate tumor type and clinical setting fields for the request to be processed.
For continuation requests the form requires documentation that addresses disease status and treatment safety: whether the patient experienced disease progression on prior PD-1/PD-L1 therapy, whether there is evidence of disease progression or unacceptable toxicity on the current regimen, and whether severe toxicities requiring continuous monitoring have occurred. The form also requests explanations for adverse events that did not respond to conventional interventions and for severe venous access issues that necessitate care in an outpatient hospital setting. Missing or inadequate documentation of these items may prevent approval.
| Intended Regimen / Combination | Notes |
|---|---|
| Single agent | |
| Form asks whether the requested medication will be used as a single agent for multiple tumor types (e.g., NSCLC, melanoma, other); provider should indicate single-agent use on initiation/continuation requests. | |
| In combination with bevacizumab (Avastin) | |
| Form includes a specific question about use in combination with bevacizumab for indications including HCC and NSCLC; provider must check Yes/No. | |
| In combination with etoposide + cisplatin or carboplatin | |
| Form asks whether the medication will be used with etoposide and either cisplatin or carboplatin (small cell lung cancer / extensive-stage disease and other settings). | |
| In combination with cobimetinib (Cotellic) + vemurafenib (Zelboraf) | |
| Form asks for BRAF V600 mutation status for melanoma and whether the medication will be used in combination with cobimetinib and vemurafenib. | |
| In combination with chemotherapy (with or without bevacizumab) | |
| Form lists 'in combination with chemotherapy with or without bevacizumab' as an intended regimen option (e.g., NSCLC combinations). | |
| Other specified regimen (free-text) | |
| Form provides an 'Other' option allowing the provider to specify alternative regimens or combinations not explicitly listed. |
Billing and Diagnosis Codes
| Administration code(s) (CPT): | Form requests CPT administration codes to be provided by the prescriber/dispensing provider. |
| Primary ICD Code | Primary diagnosis ICD code to be entered on the form. |
| Secondary ICD Code | Secondary diagnosis ICD code to be entered on the form. |
| Other ICD Code | Additional ICD code field. |
Provider Responsibilities and Submission Requirements
Precertification required — use this form for start or continuation requests
Precertification is required for Tecentriq. Submit requests for either initiation (start of treatment) or continuation of therapy (date of last treatment) using the Tecentriq Medication Precertification Request form and Aetna Precertification Notification contact information (phone 1-866-752-7021, fax 1-888-267-3277). For Medicare Advantage Part B use the Medicare Request Form.
- Indicate whether request is Start of treatment (include start date) or Continuation of therapy (include date of last treatment).
- Include precertification requester contact: Precertification Requested By, Phone, Fax.
- For Medicare Advantage Part B, submit using the Medicare Request Form.
Document prior PD‑1/PD‑L1 therapy and specify place in therapy
Document any prior PD-1/PD-L1 inhibitor use and whether the patient experienced disease progression on a prior PD-1/PD-L1 agent; indicate the place in therapy selected on the form (first-line, initial/subsequent, continuation/maintenance) and specify intended regimen or combinations as requested.
- For initiation: answer whether the patient experienced progression while on a PD-1/PD-L1 inhibitor (e.g., nivolumab, pembrolizumab, avelumab, durvalumab).
- For continuation: indicate if the patient experienced progression while receiving another PD-1/PD-L1 inhibitor and document current regimen, maintenance status, and any combination chemotherapy (e.g., with bevacizumab, etoposide + platinum).
- Select place in therapy: First-line, Initial/Subsequent, Continued maintenance, or Subsequent therapy as applicable.
Complete form and provide all supporting clinical documentation
Complete and submit the fully legible Tecentriq Precertification Request form with all required supporting clinical documentation, including full patient demographics, insurance details, prescriber and dispensing/administration information, product dosing/frequency, and diagnosis codes.
- Patient demographics and contact information (page fields A).
- Insurance information including Aetna Member ID, group number, and other coverage (page fields B).
- Prescriber information: name, license/NPI/DEA, specialty, phone/fax (page fields C).
- Dispensing/provider and administration details: place of administration, CPT administration code(s), dispensing provider/pharmacy details (page fields D).
- Product information: requested dose and frequency (page fields E).
- Diagnosis ICD codes: primary, secondary, other (page fields F).
- Required clinical information for initiation or continuation requests (tumor type, place in therapy, biomarker status, intended regimen, documentation of progression/toxicity for continuation).
- Signature and date on the acknowledgement section (request completed by).
Fraud warning and potential penalties for misrepresentation
Do not provide materially false information or conceal material facts on the request form; doing so may constitute fraud and can result in denial of the request and civil or criminal penalties. The plan may request additional information or clarification to evaluate requests.
- Any person who knowingly submits a request with intent to defraud by providing materially false or concealed information may be subject to criminal and civil penalties.
- Aetna may request additional information or clarification as needed to evaluate the request.
Place in Therapy Definitions
Line of Therapy Criteria
first-line | subsequent | maintenance
Provider selects place in therapy on the form; a single top-level selection is required to indicate intended line of therapy.
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Required Biomarker and Mutation Status
Background and Scope
Tecentriq (atezolizumab) is a programmed death ligand-1 (PD-L1) inhibitor used across multiple tumor types and clinical settings. This precertification request form collects the clinical details Aetna needs to determine medical necessity, including tumor type and stage/setting (e.g., unresectable, metastatic, recurrent), biomarker status (such as PD-L1 or BRAF where queried), intended regimen (single agent or specific combinations such as with bevacizumab or etoposide + platinum), and the patient’s place in therapy (first-line, subsequent, maintenance/continuation). For continuation requests the form additionally requires documentation of response, progression, toxicity, infusion setting, and other safety concerns. The plan may request additional information or clarification, and knowingly providing materially false or concealing material information may be considered fraud.
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