Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Tecentriq is used to treat bladder and other urinary system cancers, a type of lung cancer, hepatocellular carcinoma, and melanoma.

2)    Tecentriq (Atezolizumab) requires prior authorization.

3)    Tecentriq is considered a specialty drug and is covered under the medical benefit.

Tecentriq (Atezolizumab) is considered medically necessary for members meeting the following conditions:

Urothelial Carcinoma

1)    Patient is 18 years of age or older; AND

2)    Patient has locally advanced or metastatic urothelial carcinoma (including bladder cancer or other urinary system cancers); AND

3)    Patient is ineligible for any platinum-containing chemotherapy (e.g. cisplatin, carboplatin, oxaliplatin) OR

4)    Patient has progressed during or following platinum-containing chemotherapy for advanced disease; OR

5)    Patient has progressed within 12 months of neoadjuvant or adjuvant platinum-containing chemotherapy.

Non-Small Cell Lung Cancer

1) Patient is 18 years of age or older; AND

2) Patient has a diagnosis of recurrent or metastatic non-small cell lung cancer; AND

3) If EGFR or ALK mutation status is negative or unknown, patient meets one of the following:

a) Disease progression on or after platinum-containing chemotherapy; OR

b) Disease is non-squamous and Tecentriq is prescribed in combination with bevacizumab, paclitaxel, and carboplatin; OR

4) If patient has EGFR or AL genomic tumor aberrations, has disease progression on

    FDA-approved EGFR- or ALK-targeted therapy.

Small Cell Lung Cancer

1)    Patient is 18 years of age or older; AND

2)    Patient has a diagnosis of small cell lung cancer; AND

3)    Will be used in combination with etoposide and carboplatin for extensive stage disease.

Breast Cancer

1)    Patient is 18 years of age or older; AND

2)    Patient has a diagnosis of unresectable locally advanced or metastatic hormone receptor (HR)-negative, HER2-negative (triple-negative) breast cancer; AND

3)    Tumors express PD-L1 (1% or more) as determined by an FDA-approved test; AND

4)    Will be used in combination with nab-paclitaxel.

Hepatocellular Carcinoma

1)    Diagnosis of hepatocellular carcinoma (HCC); and

2)    Patient is 18 years of age or older; AND

3)    Prescribed in combination with bevacizumab as first-line systemic therapy

Melanoma

1)    Diagnosis of melanoma with BRAF V600 mutation; AND

2)    Disease is unresectable or metastatic; AND

3)    Patient is 18 years of age or older; AND

4)    Prescribed in combination with cobimetinib and vemurafenib

Codes Used In This BI:

C9483   Injection, Atezolizumab, 10mg (deleted 1/1/18)

J9022   Injection, Atezolizumab, 10mg (new 1/1/18)

1)    Tecentriq Prescribing Information.  Genentech, Inc. South San Francisco, CA.

2)    Clinical Pharmacology. Accessed online June 17, 2019.

3)    NCCN Drugs and Biologics Compendium.  Accessed online October 2021.

Addendum:

1)    Effective 1/1/2018: 2018 Code Updates. Updated Claim Statement section & Codes Used in This BI section to reflect new/deleted CPT/HCPCS codes. The following code was deleted 1/1/18: C9483. This code was replaced with the following new code effective 1/1/18: J9022.

2)    Effective 8/1/2019: Added coverage criteria for small cell lung cancer and breast cancer.

3)    Effective 10/01/2019: Updated criteria for urothelial carcinoma and non-small cell lung cancer

4)    Effective 12/01/2021: Updated to include coverage criteria for hepatocellular carcinoma and melanoma.