Tecentriq (atezolizumab) — coverage criteria for oncology indications
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Policy governs coverage and prior authorization criteria for Tecentriq (atezolizumab) for approved and compendial oncology indications for Blue Cross Blue Shield - Tennessee members.
No material clinical or coverage changes in this revision.
Coverage criteria by cancer type and use case
NSCLC — covered scenarios
Authorization of 6 months may be granted for NSCLC when ALL of the following are met:
Authorization of 6 months may be granted; see documentation requirements for molecular testing.
SCLC — covered scenarios
Authorization of 6 months may be granted for SCLC when ALL of the following are met:
Authorization of 6 months may be granted.
Hepatocellular carcinoma — covered scenarios
Authorization of 6 months may be granted for HCC when ALL of the following are met:
Authorization of 6 months may be granted.
Melanoma — covered scenarios
Authorization of 6 months may be granted for melanoma when ALL of the following are met:
Authorization of 6 months may be granted; submit BRAF V600 test results.
Alveolar soft part sarcoma — covered scenarios
Authorization of 6 months may be granted for ASPS when ALL of the following are met:
Authorization of 6 months may be granted.
Cervical cancer — covered scenarios
Authorization of 6 months may be granted for cervical cancer when ANY of the following are met:
Authorization of 6 months may be granted.
Colon cancer — covered scenarios
Authorization of 6 months may be granted for colon cancer adjuvant therapy when ALL of the following are met:
Authorization of 6 months may be granted; requests not meeting biomarker and regimen criteria are excluded.
Mesothelioma — covered scenarios
Authorization of 6 months may be granted for mesothelioma when ALL of the following are met:
Authorization of 6 months may be granted.
Thymic carcinoma — covered scenarios
Authorization of 6 months may be granted for thymic carcinoma when ALL of the following are met:
Authorization of 6 months may be granted.
Adjuvant stage III colon cancer
Adjuvant treatment of stage III colon cancer — Covered when ALL of the following are met:
Authorization of 6 months may be granted.
Thymic carcinoma — initial
Thymic carcinoma — Covered when ALL of the following are met:
Authorization of 6 months may be granted.
Thymic carcinoma — reauthorization
Thymic carcinoma — Reauthorization:
Authorization of 6 months may be granted (up to 24 months total).
CLL with Richter's transformation
Chronic lymphocytic leukemia (CLL) with Richter's transformation — Covered when ALL of the following are met:
Authorization of 6 months may be granted.
Adjuvant HCC, NSCLC, colon — reauthorization
Adjuvant treatment reauthorization for HCC, NSCLC, and colon cancer — Covered when ALL of the following are met:
Authorization of 6 months may be granted (up to 12 months total).
Other indications — reauthorization
Reauthorization for other listed indications — Covered when ALL of the following are met:
Authorization of 6 months may be granted.
All indications for Tecentriq (atezolizumab) not specifically listed in the Coverage Criteria section — i.e., uses outside the FDA‑approved indications and the compendial uses enumerated in this policy — are considered experimental/investigational and are not medically necessary for purposes of coverage.
Requests for adjuvant treatment of stage III colon cancer that do not meet the policy’s biomarker and regimen requirements are excluded from coverage. To be eligible, the member’s disease must be confirmed dMMR/MSI‑H or POLE/POLD1 mutation with an ultra‑hypermutated phenotype (TMB >50 mut/Mb), and Tecentriq must be used in combination with FOLFOX or CAPEOX followed by single‑agent maintenance.
Coverage will not be provided for members who have experienced disease progression while on a PD‑1 or PD‑L1 inhibitor.
Requests for reauthorization will be denied when there is evidence of disease progression or unacceptable toxicity while the member is on the current regimen. Reauthorization is only appropriate when documentation shows no progression and no unacceptable treatment‑related toxicity.
Regimens and combination therapies covered
| Indication | Regimen / Required Combinations | Authorization Notes |
|---|---|---|
| NSCLC — First-line metastatic (non-squamous) | ||
| Tecentriq + bevacizumab + paclitaxel + carboplatin | ||
| Tecentriq + paclitaxel protein-bound + carboplatin | ||
| Authorization: 6 months may be granted for first-line therapy; used as first line in combination with chemotherapy with or without bevacizumab. | ||
| NSCLC — First-line metastatic (high PD-L1, single-agent) | ||
| Tecentriq as single agent for tumors with PD-L1 ≥ 50% (TC ≥ 50% or IC ≥ 10%) and no EGFR/ALK aberrations | ||
| Authorization: May be used as first-line single agent; authorization durations consistent with clinical scenario. | ||
| NSCLC — Adjuvant (stage II–IIIA) | ||
| Tecentriq as single agent following resection and platinum-based chemotherapy for stage II–IIIA with PD-L1 ≥ 1% (FDA-approved test) | ||
| Authorization: 6 months may be granted for adjuvant therapy for stage IB–III PD-L1 positive when no EGFR exon 19 deletions/L858R mutations or ALK rearrangements are present (unless testing not feasible). | ||
| NSCLC — Subsequent therapy (progressive disease) | ||
| Tecentriq as single agent for metastatic NSCLC after progression on platinum-containing chemotherapy | ||
| Authorization: 6 months may be granted for single-agent subsequent therapy. |
| Requirement | Details |
|---|---|
| Combination regimen requirements | |
| For NSCLC first-line metastatic non-squamous: Atezolizumab must be used with one of the specified regimens — either with bevacizumab + paclitaxel + carboplatin OR with paclitaxel protein-bound + carboplatin. | |
| For colon cancer (adjuvant, stage III): Atezolizumab must be used in combination with FOLFOX or CAPEOX, followed by single-agent maintenance; member must have dMMR/MSI-H or POLE/POLD1 ultra-hypermutated phenotype (TMB >50 mut/Mb). | |
| For thymic carcinoma: Atezolizumab must be used in combination with carboplatin + paclitaxel followed by single-agent maintenance. | |
| For CLL with Richter's transformation: Atezolizumab must be used in combination with venetoclax + obinutuzumab. | |
| For SCLC (extensive-stage): Atezolizumab must be used in combination with carboplatin + etoposide, followed by maintenance as single agent or with lurbinectedin. | |
| For HCC unresectable/metastatic (and adjuvant following resection/ablation): Atezolizumab must be used in combination with bevacizumab. | |
| Authorization notes | |
| Providers should document tumor biomarker results (PD-L1, EGFR/ALK status, dMMR/MSI-H, TMB, BRAF when applicable) and specify the exact chemo/immunotherapy combination on the prior authorization to avoid denial risk. |
Provider action: NSCLC usage pathways
Provider action: NSCLC usage pathways — ensure appropriate diagnostic testing and document the chosen regimen. - Confirm and document EGFR and ALK genomic aberration testing before using combination regimens in metastatic NSCLC; if EGFR or ALK aberrations are present, verify progression on indicated targeted therapies prior to atezolizumab use. - For single-agent adjuvant use, document PD-L1 expression (≥ 1%) and absence of EGFR exon 19 deletions/L858R or ALK rearrangements unless testing not feasible. - For high PD-L1 single-agent first-line treatment, document PD-L1 ≥ 50% (TC ≥ 50% or IC ≥ 10%) and absence of EGFR/ALK aberrations. - When requesting authorization for combination regimens, specify the exact chemotherapy backbone (e.g., bevacizumab + paclitaxel + carboplatin OR paclitaxel protein-bound + carboplatin) and attach relevant pathology/molecular reports.
Biomarker and molecular testing requirements
Provide required biomarker and molecular test results
Submit supporting laboratory or molecular test reports with the prior authorization request showing the specific biomarker results relevant to the indication.
- BRAF V600 mutation test results when applicable (e.g., melanoma).
- PD‑L1 tumor expression results when applicable (e.g., NSCLC adjuvant/metastatic thresholds).
- Documentation of absence of EGFR exon 19 deletions or L858R mutations and absence of ALK rearrangements when applicable for NSCLC.
Colon cancer: submit biomarker and regimen documentation
For adjuvant stage III colon cancer requests, include documentation that the tumor is dMMR/MSI‑H or has a POLE/POLD1 mutation with ultra‑hypermutated TMB (>50 mut/Mb) and that atezolizumab will be given in combination with FOLFOX or CAPEOX followed by single‑agent maintenance.
- Test report confirming dMMR/MSI‑H or POLE/POLD1 with TMB >50 mut/Mb.
- Planned regimen documentation showing combination use with FOLFOX or CAPEOX and intended single‑agent maintenance.
Permitted lines of therapy and maintenance use
first-line | subsequent | maintenance
first-line
adjuvant
Document NSCLC treatment pathway and testing
For NSCLC, document the intended usage pathway: continued maintenance single‑agent (with or without bevacizumab), first‑line or subsequent therapy in combination with chemotherapy (with or without bevacizumab), or first‑line single‑agent use where indicated.
- If applicable, include PD‑L1 and EGFR/ALK testing results (absence of EGFR exon 19 deletions/L858R and ALK rearrangements when feasible).
- Indicate whether the request is for maintenance, first‑line, or subsequent therapy and list concomitant therapies (chemotherapy and/or bevacizumab).
Authorization, documentation, and reauthorization actions
Prior authorization required — 6 month approvals
Prior authorization is required; when indication‑specific clinical criteria are met, authorization may be granted for a 6‑month period.
- See the Coverage Criteria section for indication‑specific requirements that support a 6‑month approval.
Authorization duration — initial and reauthorization
Initial authorizations and reauthorizations are typically approved for 6 months; certain indications have defined total‑duration caps for continued treatment.
- Adjuvant HCC, NSCLC, and colon reauthorization: may be granted for 6 months (up to 12 months total) if no recurrence or unacceptable toxicity.
- Thymic carcinoma reauthorization: may be granted for 6 months (up to 24 months total) if no progression or unacceptable toxicity.
Document specified combination regimens
Operationally, confirm and document the required combination chemotherapy regimen when the indication specifies combination use; requests lacking regimen documentation may be denied.
- Adjuvant colon cancer: FOLFOX or CAPEOX documented.
- Thymic carcinoma: carboplatin + paclitaxel documented.
- CLL Richter's: venetoclax + obinutuzumab documented.
Required clinical documentation for PA and reauthorization
Include clinical documentation demonstrating diagnosis, relevant biomarker results, planned or ongoing combination chemotherapy regimens, and treatment dates to support the prior authorization request or reauthorization.
- Diagnosis and staging information.
- Laboratory/pathology reports for biomarkers (e.g., PD‑L1, BRAF V600, dMMR/MSI‑H, POLE/POLD1 with TMB).
- Planned or current combination therapy details and treatment initiation/continuation dates.
- For reauthorization, documentation that there is no disease recurrence/progression or unacceptable toxicity.
Exclude members with prior PD‑(L)1 progression
Do not request coverage for members who have experienced disease progression while receiving PD‑1 or PD‑L1 inhibitor therapy; such members are excluded from coverage under this policy.
- Evidence of disease progression on a PD‑1 or PD‑L1 inhibitor will make the member ineligible for coverage.
CLL (Richter's): combination regimen must be documented
Requests for CLL with Richter's transformation must document that atezolizumab will be used in combination with venetoclax and obinutuzumab; absence of this regimen documentation risks denial.
- Provide regimen orders or treatment plan showing concurrent use with venetoclax and obinutuzumab.
Billing codes, dosing, and diagnostic thresholds
| affected codes | Placeholder — specific HCPCS/CPT/NDC codes referenced in subsequent policy sections (not present in this partial document). |
| 840 mg q2w | Intravenous dosing option for Tecentriq (Atezolizumab) for adults (≥18 years) as listed in medication quantity limits. |
| 1200 mg q3w | Intravenous dosing option for Tecentriq (Atezolizumab); also listed as initial 1200 mg every 3 weeks for 4-6 doses for certain indications with maintenance dosing options. |
| 1680 mg q4w | Intravenous dosing option for Tecentriq (Atezolizumab) for adults as listed in medication quantity limits and as a maintenance option for some indications. |
| 15 mg/kg q3w (up to 1200 mg) | Pediatric dosing (≥2 to <18 years): 15 mg/kg every 3 weeks, up to a maximum of 1200 mg every 3 weeks. |
Drug background and context
Tecentriq (atezolizumab) is an anti‑programmed death‑ligand 1 (PD‑L1) immune checkpoint inhibitor used across multiple oncology indications. The agent is administered intravenously and is indicated or used in combination regimens for various cancers covered by this policy (for example, lung cancers, hepatocellular carcinoma, melanoma, alveolar soft part sarcoma and select compendial uses). Coverage decisions in this policy are tied to specific tumor biomarkers (such as PD‑L1 expression, dMMR/MSI‑H, POLE/POLD1 with TMB >50 mut/Mb, BRAF V600, and absence of certain EGFR/ALK alterations where applicable) and to FDA‑approved single‑agent or combination regimens and lines of therapy.
Key definitions and phenotype thresholds
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