BlueCross BlueShield of Tennessee Medical Policy Manual

Atezolizumab

NDC CODE(S)

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

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

DESCRIPTION

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.

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

 

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

PD-L1 expression-positive tumors (≥50%)

  • Pembrolizumab

 

RENEWAL CRITERIA

INDICATION(S)

DOSAGE & ADMINISTRATION

Triple Negative Breast Cancer

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

All other indications

1200 mg intravenously every 21 days until disease progression or unacceptable toxicity

LENGTH OF AUTHORIZATION

Coverage will be provided for six months and may be renewed

Refer to DOSAGE LIMITS below

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

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.

IMPORTANT REMINDER

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.

ADDITIONAL INFORMATION 

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).

SOURCES

Lexicomp Online. (2019, February). AHFS DI. Atezolizumab. Retrieved April 11, 2019 from Lexicomp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Evaluations. (2019, March). Atezolizumab. April 11, 2019 from MICROMEDEX Healthcare Series.

National Comprehensive Cancer Network. (2019). NCCN Drugs & Biologics Compendium®. Atezolizumab. Retrieved April 11, 2019 from the National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2019, March). Center for Drug Evaluation and Research. Tecentriq® (atezolizumab) injection, for intravenous use.  Retrieved April 11, 2019 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/761034s001lbl.pdf.

ORIGINAL EFFECTIVE DATE: 6/7/2016

MOST RECENT REVIEW DATE:  7/31/2019

ID_MRx

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.

This document has been classified as public information.

 

 

DOSAGE LIMITS

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

DIAGNOSIS

BILLABLE UNIT

MAXIMUM UNITS

Triple Negative Breast Cancer

10 mg = 1 billable unit

84 billable units every 21 days

All other indications

10 mg = 1 billable unit

120 billable units every 21 days