Fillable MVASI (bevacizumab-awwb) ZIRABEV (bevacizumab-bvzr) Medication Precertification Request AVASTIN (Aetna Health Insurance)

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MVASI (bevacizumab-awwb) ZIRABEV (bevacizumab-bvzr) Medication Precertification Request AVASTIN (Aetna Health Insurance)

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  • 78 other fields

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AVASTIN™ (bevacizumab)
MVASI™ (bevacizumab-awwb)
ZIRABEV™ (bevacizumab-bvzr)
Medication Precertification Request
Page 1 of 3
Aetna Precertification Notification
Phone: 1-866-752-7021
FAX: 1-888-267-3277
For Medicare Advanta
ge Part B:
Pho
n
e: 1-866-503-0857
FAX: 1-844-268-7263
(All fields must be completed and legible for precertification review.)
Please indicate: Start of treatment: Start date / /
Continuation of therapy, Date of last treatment / /
Precertification Requested By: Phone: Fax:
A. PATIENT INFORMATION
First Name: Last Name: DOB:
Address: City: State: ZIP:
Home Phone: Work Phone: Cell Phone: Email:
Patient Current Weight: lbs or kgs Patient Height: inches or cms Allergies:
B. INSURANCE INFORMATION
Aetna Member ID #:
Group #:
Insured:
Does patient have other coverage?
Yes No
If yes, provide ID#:
Carrier Name:
Insured:
Medicare: Yes No If yes, provide ID #: Medicaid: Yes No If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name: Last Name: (Check One): M.D. D.O. N.P. P.A.
Address: City: State: ZIP:
Phone: Fax: St Lic #: NPI #: DEA #: UPIN:
Provider Email: Office Contact Name: Phone:
Specialty (Check one): Oncologist Ophthalmologist Other:
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Self-administered Physician’s Office
Outpatient Infusion Center Phone:
Center Name:
Home Infusion Center Phone:
Agency Name:
Administration code(s) (CPT):
Address:
Dispensing Provider/Pharmacy: Patient Selected choice
Physician’s Office Retail Pharmacy
Specialty Pharmacy Other
Name:
Address:
Phone: Fax:
TIN: PIN:
E. PRODUCT INFORMATION
Request is for: AVASTIN (bevacizumab) MVASI (bevacizumab-awwb) ZIRABEV (bevacizumab-bvzr)
Dose:
Frequency:
F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other where applicable.
Primary ICD Code: Secondary ICD Code: Other ICD Code:
G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests.
For Initiation Requests (clinical documentation required for all requests):
Ophthalmic disorders:
Is this request for Avastin treatment? Yes No
Has the patient tried and failed treatment with Avastin due to a documented intolerable adverse event
(e.g., rash, nausea, vomiting)?
Yes No
Was the adverse event unexpected and not attributed to the active ingredient as described in the prescribing information? Yes No
Please select the diagnosis:
Choroidal neovascularization (CNV) (including myopic choroidal neovascularization (mCNV), angioid streaks, choroiditis [including choroiditis secondary
to ocular histoplasmosis], idiopathic degenerative myopia, retinal dystrophies, rubeosis iridis, pseudoxanthoma elasticum, and trauma)
Diabetic macular edema
Macular edema following retinal vein occlusion (RVO)
Neovascular (wet) Age-Related Macular Degeneration (AMD)
Neovascular glaucoma
Polypoidal choroidal vasculopathy
Proliferative diabetic retinopathy
Retinopathy of prematurity
Continued on next pag
e
GR-69556 (2-22)
GR-69556 (2-22)
Continued on next page.
AVASTIN™ (bevacizumab)
MVASI™ (bevacizumab-awwb)
ZIRABEV™ (bevacizumab-bvzr)
Medication Precertification Request
Page 2 of 3
(All fields must be completed and legible for precertification review.)
Aetna Precertification Notification
Phone: 1-866-752-7021
FAX: 1-888-267-3277
For Medicare Advantage Part B:
Pho
ne: 1-866-503-0857
FAX: 1-844-268-7263
Patient First Name Patient Last Name Patient Phone Patient DOB
G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification
Oncology indications:
Is this request for Mvasi treatment? Yes No
Has the patient tried and failed treatment with Mvasi due to a document
ed intolerable adverse event
(e.g., rash, nausea, vomiting)?
Yes No
Was the adverse event unexpected and not attributed to the active ingredient as described in the prescribing information? Yes No
Please selec
t the diagnosis:
Anaplastic glioma
Angiosarcoma
Will the requested me
dication be given as a single agent therapy? Yes No
Breast cancer
Does the patient have recurrent or metastatic disease? Yes
Please select: recurrent disease metastatic disease none of the above
No
Cervical cancer
Does the patient have persistent, recurrent, or metastatic disease? Yes
Please select: persistent disease recurrent disease metastatic disease none o
f the above
No
Colorectal cancer, including appendiceal adenocarcinoma and an
al adenocarcinoma
Glioblastoma
Endometrial carcinoma
Does the patient have progressive, advanced, recurrent,
or metastatic disease? Yes
Please select: progressive disease advanced disease recurrent disease metastatic disease none of the above
No
Epithelial ovarian cancer (including carcinosarcoma [malignant mixed Müllerian tumors], clear cell carcinoma, mucinous carcinoma, endometrioid
carcinoma, serous
carcinoma, borderline epithelial tumors [low malignant potential] with invasive implants, and malignant sex cord-stromal tumors)
Fallopian tube cancer
Hepatocellular carcinoma
Does the patient have
unresectable or
metastatic disease? Yes
Please select:
unresectable disease metastatic disease none of the above
No
Will the requested drug be used as initial treatment? Yes No
Will the requested medication be given in combination with atezolizumab (Tecentriq)?
Yes No
Intracranial and spinal ependymoma (excludes subependymoma)
Limited and extensive brain metastases
Low-grade (WHO Grade 1 or 2
) Glioma
Medulloblastoma
Meningiomas
Metastatic spine tumors
Non-squamous non-small cell lung cancer (NSCLC)
Does the patient have recurrent, advan
ced, metastatic, or unresectable
disease? Yes
Please
select: re
current disease advanced disease metastatic disease unresectable disease
none of the above
No
Mesothelioma
Please indicate the type of mesothelioma which applies to the patient’s disease:
malignant pleural mesothelioma malignant peritoneal mesothelioma pericardial mesothelioma tunica vaginalis testis mesothelioma
other
Please indicate t
he place in therapy in which the requested drug will be used:
First-line treatment
Will the requested med
ication be given in combination with pemetrexed
(Alimta) and either cisplatin (Platinol) or carboplatin
(Paraplatin), follo
wed by single-agent maintenance bevacizumab?
Yes No
Does the patient have unresectable disease? Yes No
Subsequent treatment
Please select the requested regimen:
In combination with pemetrexed (Alimta) and either cisplatin (Platinol) or carbo
platin (Paraplatin)
Has the patient received immunotherapy as first-line treatment? Yes No
In combination with atezolizumab (Tecent
riq)
Other
Primary central nervous system lymphoma
Primary peritoneal cancer
Renal cell carcinoma
Does the patient have relapsed or stag
e IV disease? Yes re
lapsed disease stage IV disease none of the above No
AVASTIN™ (bevacizumab)
MVASI™ (bevacizumab-awwb)
ZIRABEV™ (bevacizumab-bvzr)
Medication Precertification Request
Page 3 of 3
(All fields must be completed and legible for precertification review.)
Aetna Precertification Notification
Phone: 1-866-752-7021
FAX: 1-888-267-3277
For Medicare Advantage Part B:
Pho
ne: 1-866-503-0857
FAX: 1-844-268-7263
Patient First Name Patient Last Name Patient Phone Patient DOB
G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests
Small bowel adenocarcinoma, including advanced ampullary cancer
Solitary fibrous tumor or hemangiopericytoma
Will the requested medication be given in combination with temozolomide? Yes No
Vaginal cancer
Does the patient have persistent, recurrent, or metastatic disease? Yes
Please select: persistent disease recurrent disease metastatic disease none of the above
No
Uterine neoplasms
Does the patient have progressive, advanced, recurrent, or metastatic disease? Yes
Please select: progressive disease advanced disease recurrent disease metastatic disease none of the above
No
Vulvar squamous cell carcinoma
Does the patient have unresectable locally advanced, recurrent, or metastatic disease? Yes
Please select: unresectable locally advanced disease recurrent disease metastatic disease none of the above
No
For Continuation Requests (clinical documentation required for all requests):
Ophthalmic disorders:
Has the patient demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA]
or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss)?
Yes No
Oncology indications:
Has the patient experienced an unacceptable toxicity or disease progression while on the current regimen? Yes No
H. ACKNOWLEDGEMENT
Request Completed By (Signature Required): Date:
/ /
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive
any insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties.
The plan may request additional information or clarification, if needed, to evaluate requests.
GR-69556 (2-22)
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MVASI (bevacizumab-awwb) ZIRABEV (bevacizumab-bvzr) Medication Precertification Request AVASTIN (Aetna Health Insurance)

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Completed 5 May 2022

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