Tecentriq (atezolizumab)

Authorization form

Traditional, Optimized & Medicaid (11/2018)

No prior authorization required for Medicare

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J9999, C9483

Benefit: Medical

Notes: Treatment of urothelial cancer 

Criteria for coverage:

  • See PA form for criteria for Commercial and Medicaid

  • PA for Medicare

    • This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

  • Refer to CMS local coverage determination criteria for Part B when available.