CurrentEmblemHealthPolicy MG.MM.PH.169

Tecentriq (atezolizumab) Intravenous and Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) Subcutaneous

Defines coverage, coding, and limitations for Tecentriq (atezolizumab) for specified oncologic indications and affected members of EmblemHealth/ConnectiCare.

Policy Summary

PayerEmblemHealth

PolicyTecentriq (atezolizumab) Intravenous and Tecentriq Hybreza Subcutaneous

Policy CodePolicy MG.MM.PH.169

Change TypeAdded formulation (Hybreza)multiple material updates

Effective Date

Next Review DateOct 17, 2024

Key ActionSubmit prior authorization with documented PD-L1 testing, prior therapies, and specific NDC for the Tecentriq vial used.

SourceLink

POLICY UPDATE CHANGES

Added Tecentriq Hybreza, updated dosing limits, Jcodes, NDCs, dosing.

Updated the age limit for Alveolar Soft Part Sarcoma to 'Patient is ≥ 2 years of age (Tecentriq) or Patient is > 18 years of age (Tecentriq Hybreza)'.

Added limitation: 'Therapy will not be used concomitantly with intravenous atezolizumab'.

Added limitation: 'Patients <62 kg should use the IV formulation of Tecentriq'.

Removed Bladder Cancer Indication and Criteria.

Added examples of prior immune checkpoint therapies to clarify prior use exclusions (e.g., nivolumab, pembrolizumab, durvalumab, avelumab, cemiplimab, dostarlimab, etc.).

Added renewal limit: NSCLC (Adjuvant Treatment) - Patient has not exceeded 12 months of therapy.

>=1PD-L1 threshold referenced

3NDC presentations

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Indications

NSCLC and related indications

Coverage for NSCLC and related indications as updated per FDA label and policy revision; specific criteria include age, biomarker status, prior therapies, combination regimens, and duration limits.

NSCLC adjuvant: Patient is ≥ 18 years and Tecentriq is used as adjuvant treatment following resection and platinum-based chemotherapy for Stage II to IIIA NSCLC with PD-L1 expression ≥ 1% as determined by an FDA-approved testPD-L1 ≥1%

Renewal limited to not exceeding 12 months of therapy

NSCLC metastatic first-line single-agent: Patient meets criteria for first-line single-agent treatment of metastatic NSCLC with high PD-L1 expression (TC ≥50% or IC ≥10%) with no EGFR or ALK genomic tumor aberrationsPD-L1 TC ≥50% or IC ≥10%

Members with EGFR/ALK aberrations must have progressed on FDA-approved targeted therapy prior to Tecentriq

NSCLC combination regimens: Tecentriq in combination with bevacizumab, paclitaxel and carboplatin, or with paclitaxel protein-bound and carboplatin, is indicated for first-line treatment of metastatic non-squamous NSCLC without EGFR or ALK aberrationsnone

Follow FDA-approved combination indications

Other FDA label indications

Other FDA-aligned indications and updates included previously and in prior revisions.

Hepatocellular carcinoma (HCC): Tecentriq indicated in combination regimens for HCC as per FDA labelnone

See dosing and combination guidance in full policy

Melanoma (BRAF V600): Indication for BRAF V600 mutation-positive unresectable or metastatic melanoma per FDA labelBRAF V600 mutation documented

Follow FDA label dosing

Small cell lung cancer (SCLC): Tecentriq in combination with carboplatin and etoposide for first-line treatment of extensive-stage SCLCnone

The policy has removed the Bladder Cancer indication and its associated coverage criteria in this version. This change was documented in the revision history noting: "Removed Bladder Cancer Indication and Criteria."

The policy specifies that therapy will not be used concomitantly with intravenous atezolizumab. This limitation was added to the Limitations and Exclusions section in the 10/17/2024 revision to operationalize the new subformulation and prevent concurrent use of two atezolizumab formulations.

Use of Tecentriq for indications that were removed from this policy (for example, the previously listed Bladder Cancer indication) is considered not covered under this version and may be denied.

Covered Regimens and Combination Therapies

Regimen	Indication	Coverage
Tecentriq + bevacizumab + paclitaxel + carboplatin
First-line treatment of adult patients with metastatic non-squamous non-small cell lung cancer (NSCLC) with no EGFR or ALK genomic tumor aberrations
Covered with criteria
Tecentriq + paclitaxel protein-bound + carboplatin
First-line treatment of adult patients with metastatic non-squamous NSCLC with no EGFR or ALK genomic tumor aberrations
Covered with criteria

Regimen	Indication	Coverage
Tecentriq in combination with carboplatin and etoposide
First-line treatment of adult patients with extensive-stage small cell lung cancer (SCLC)
Covered with criteria

Regimen	Indication	Coverage
Tecentriq in combination regimens per FDA label (e.g., atezolizumab-containing combinations indicated for hepatocellular carcinoma)
Treatment of hepatocellular carcinoma (HCC) in combinations as approved in the FDA label
Covered with criteria

Billing Codes and Diagnosis Codes

Applicable NDCsNDC

50242-0917-xx	Tecentriq 1200mg/20mL single use vial
50242-0918-xx	Tecentriq 840mg/14mL single use vial
50242-0933-xx	Tecentriq 1,875 mg and 30,000 units/15 mL in a single-dose vial

ICD-10 DiagnosesICD-10Covered

C22.0	Liver cell carcinoma, hepatocellular carcinoma
C22.8	Malignant neoplasm of liver, primary, unspecified as to type
C33	Malignant neoplasm of trachea
C34.00	Malignant neoplasm of unspecified main bronchus
C34.01	Malignant neoplasm of right main bronchus
C34.02	Malignant neoplasm of left main bronchus
C34.10	Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11	Malignant neoplasm of upper lobe, right bronchus or lung
C34.12	Malignant neoplasm of upper lobe, left bronchus or lung
C34.2	Malignant neoplasm of middle lobe, bronchus or lung

1–10 of 60

1/6

inv-08: PD-L1 expression thresholds — ≥1% and ≥50% (TC ≥50% or IC ≥10% for high expression)

PD-L1 threshold (adjuvant)PD-L1 expression on ≥1% of tumor cells as determined by an FDA‑approved test

PD-L1 threshold (first‑line high expression)PD‑L1 stained ≥50% of tumor cells (TC ≥50%)

PD-L1 threshold (first‑line immune cells)PD‑L1 stained tumor‑infiltrating immune cells covering ≥10% of the tumor area (IC ≥10%)

inv-09: Weight threshold for formulation selection — < 62 kg use IV formulation

Weight thresholdPatients <62 kg should use the IV formulation of Tecentriq

Formulation operationalization

Prior Authorization and Documentation Requirements

Documentation Required

Prior Authorization Required — Documentation

Prior authorization is required. Document prior therapies including prior use of immune checkpoint inhibitors and confirm PD-L1 testing when required by the indication. For NSCLC indications that require PD-L1 status, record the PD-L1 expression level and the FDA-approved test used.

Record PD-L1 % and assay name for NSCLC indications requiring PD-L1.
List prior immune checkpoint inhibitor therapies (e.g., nivolumab, pembrolizumab, durvalumab, avelumab, cemiplimab, dostarlimab, etc.).

Prior Authorization

Targeted Therapy Required for EGFR/ALK‑positive NSCLC

Patients with EGFR or ALK genomic tumor aberrations must have disease progression on an FDA‑approved targeted therapy for that aberration before Tecentriq may be authorized.

Document the specific targeted agent(s) used and evidence of disease progression while on that therapy.

Line of Therapy Criteria

first-line — coverage criteria node

First-line metastatic NSCLC: Patient is an adult with metastatic NSCLC whose tumor has high PD-L1 expression (TC ≥50% or IC ≥10%) and no EGFR or ALK genomic tumor aberrations; appropriate for first-line single-agent or FDA-approved combination regimensPD-L1 TC ≥50% or IC ≥10%

For patients with EGFR or ALK aberrations, disease progression on FDA-approved targeted therapy is required prior to Tecentriq

adjuvant — coverage criteria node

Adjuvant NSCLC: Patient is ≥ 18 years and Tecentriq is used as adjuvant treatment following resection and platinum-based chemotherapy for Stage II–IIIA NSCLC with PD-L1 expression ≥ 1% as determined by an FDA-approved testPD-L1 ≥1%

Renewal limited to not exceeding 12 months of therapy

Biomarker and Molecular Test Requirements

inv-21: PD-L1 thresholds — ≥1% for adjuvant; ≥50% TC or IC ≥10% for high-expression first-line single-agent

Adjuvant PD-L1 requirementPD-L1 expression on ≥1% of tumor cells (FDA‑approved test) for adjuvant NSCLC following resection and platinum‑based chemotherapy

First‑line single‑agent high PD-L1High PD‑L1 defined as TC ≥50% or IC ≥10% for first‑line single‑agent metastatic NSCLC (no EGFR/ALK aberrations)

Combination regimens noteFirst‑line combination regimens for metastatic non‑squamous NSCLC follow FDA label (no EGFR/ALK aberrations) — see full policy for specifics

inv-22: BRAF V600 — mutation positive requirement

Biomarker requirementBRAF V600 mutation must be documented as mutation‑positive for the melanoma indication

Follow FDA label

Definitions and High-Expression Criteria

inv-17: PD-L1 ≥ 50% tumor cells (TC ≥ 50%) or IC ≥ 10% tumor area — high PD-L1 expression definition

Definition (TC)High PD‑L1 expression: PD‑L1 stained ≥50% of tumor cells (TC ≥50%)

Definition (IC)High PD‑L1 expression: PD‑L1 stained tumor‑infiltrating immune cells covering ≥10% of the tumor area (IC ≥10%)

Determination methodPD‑L1 expression levels determined by an FDA‑approved test per label

Background

Atezolizumab (Tecentriq) is an anti‑PD‑L1 immune checkpoint inhibitor indicated for multiple cancer types, including certain non‑small cell lung cancer (NSCLC) settings and hepatocellular carcinoma when used in FDA‑approved regimens. Its use is guided by tumor biomarkers such as PD‑L1 expression (e.g., thresholds of ≥ 1% or high expression defined as TC ≥ 50% or IC ≥ 10%), and by prior therapies and approved combination regimens as described in the policy.