BlueCross BlueShield of Tennessee Medical Policy Manual



50242-0917-XX Tecentriq 1200 MG/20ML SOLN (GENENTECH

50242-0918-XX Tecentriq 840 MG/14ML SOLN (GENENTECH)


Atezolizumab is a monoclonal antibody that binds to programmed death-ligand 1 (PD-L1), a transmembrane protein which may be expressed on tumor cells and/or tumor-infiltrating immune cells and are often increased.  By binding to the receptors on PD-L1, atezolizumab prevents its binding to the PD-1 and B7.1 receptors found on T cells and antigen presenting cells.  This releases the PD-L1/PD-1 mediated inhibition of the immune response and activates the body’s own anti-tumor immune response, leading to decreased tumor growth.




*If platinum treatment occurred greater than 12 months ago, the patient should be re-treated with platinum-based therapy. Patients with comorbidities (e.g., hearing loss, neuropathy, poor PS, renal insufficiency, etc.) may not be eligible for cisplatin. Carboplatin may be substituted for cisplatin particularly in those patients with a GFR <60 mL/min or a PS of 2.

      • Breast Cancer and ALL of the following:

        • Used in combination with albumin-bound paclitaxel

        • Individual has triple-negative disease (TNBC) that is unresectable locally advanced, recurrent or metastatic

        • Individual has a PD-L1 expression of ≥ 1% (As confirmed using an FDA approved assay

      • Non-small cell lung cancer (NSCLC) and individual has recurrent (excluding locoregional recurrence or symptomatic local disease without evidence of disseminated disease), advanced, or metastatic disease and ANY ONE of the following:

        • Used in combination with carboplatin, paclitaxel, and bevacizumab for non-squamous disease for ANY ONE of the following:

          • Used as first-line therapy for genomic tumor aberration (i.e., EGFR, ALK) negative or unknown** and/or PD-L1 expression-positive (≥1%) in individuals with PS 0-2

          • Used as first-line therapy for genomic tumor aberration (i.e., EGFR, ALK, ROS1, BRAF) negative or unknown** and PD-L1 <1% or unknown in individuals  with PS 0-1

          • Used for BRAF V600E-mutation positive tumors in individuals with PS 0-1

          •  Used as subsequent therapy for genomic tumor aberration (i.e., EGFR, ALK, ROS1) positive and prior targeted therapy in individuals with PS 0-1

          • Used as subsequent therapy for PD-L1 expression-positive (≥ 1%) and EGFR, ALK negative or unknown** with no prior platinum doublet therapy in individuals with PS 0-1

        • Used as continuation maintenance therapy as a single agent or in combination with bevacizumab in individuals with non-squamous disease and a PS ≤ 2 for ALL of the following:

          • Individual is genomic tumor aberration (i.e., EGFR, ALK) negative or unknown**, and PD-L1 expression-positive (≥1%)

          • Individual achieved tumor response or stable disease following initial therapy in combination with carboplatin, paclitaxel, and bevacizumab

        •  Used as subsequent therapy as a single-agent in individuals with a PS ≤ 2 AND Disease progressed during or following cytotoxic therapy (e.g., platinum-containing) that did not include priorPD-1/PD-L1 inhibitor therapy

** (Every effort needs to be made to establish the genetic alteration status. A blood assay may be used if a tissue

      • assay is not feasible). 

        • Small Cell Lung Cancer(SCLC) and ALL of the following:

        • Used in combination with etoposide and carboplatin


Genomic Aberration Targeted Therapies

(not all inclusive)

Sensitizing EGFR mutation-positive tumors

  • Erlotinib

  • Afatinib

  • Gefitinib

  • Osimertinib

  • Dacomitinib

ALK rearrangement-positive tumors

  • Crizotinib

  • Ceritinib

  • Brigatinib

  • Alectinib

  • Lorlatinib

ROS1 rearrangement-positive tumors

  • Crizotinib

  • Ceritinib

BRAF V600E-mutation positive tumors

  • Dabrafenib/Trametinib

 NTRK Gene Fusion positive tumors

  • Larotrectinib

PD-L1 expression-positive tumors (≥1%)

  • Pembrolizumab





Breast Cancer- Triple negative (TNBC)

840 mg intravenously on days 1 and 15 of a 28-day cycle until disease

progression or unacceptable toxicity


The recommended dosage is administered intravenously until disease progression or unacceptable toxicity:

·   840 mg every 2 weeks or

·   1200 mg every 3 weeks or

·   1680 mg every 4 weeks


Single Agent

The recommended dosage is administered intravenously until disease progression or unacceptable toxicity:

·   840 mg every 2 weeks or

·   1200 mg every 3 weeks or

·   1680 mg every 4 weeks

Combination Therapy

The recommended dosage is administered intravenously until disease progression or unacceptable toxicity:

·   1200 mg every 3 weeks; then revert to single-agent therapy dosing after completion of 4-6 cycles of combination therapy


Coverage will be provided for six months and may be renewed

Refer to DOSAGE LIMITS below


BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.


We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.


For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).


Lexicomp Online. (2019, June). AHFS DI. Atezolizumab. Retrieved July 17, 2019 from Lexicomp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Evaluations. (2019, July). Atezolizumab. July 17, 2019 from MICROMEDEX Healthcare Series.

National Comprehensive Cancer Network. (2019). NCCN Drugs & Biologics Compendium®. Atezolizumab. Retrieved July 17, 2019 from the National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2019, May). Center for Drug Evaluation and Research. Tecentriq® (atezolizumab) injection, for intravenous use.  Retrieved July 17, 2019 from




Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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Maximum billable units per dose and over time by indication as a Medical Benefit




All indications

10 mg = 1 billable unit

84 billable  units every 14 days