Neighborhood Health Plan RI atezolizumab Coverage Update

Coverage Criteria and Indications

Alveolar Soft Part Sarcoma (ASPS)

Covered indications (selected examples from policy):

ASPS monotherapy: Tecentriq may be used as monotherapy for unresectable or metastatic alveolar soft part sarcoma in patients ≥2 years of age.

Tecentriq Hybreza (SC) may be substituted for IV atezolizumab only in adult members.

Hepatocellular Carcinoma (HCC)

Hepatocellular carcinoma indications: Atezolizumab in combination with bevacizumab or a bevacizumab biosimilar may be used as adjuvant therapy after resection or ablation in adult members with hepatocellular carcinoma (Child-Pugh Class A) who are at high risk of recurrence OR as first-line therapy for unresectable or metastatic Child-Pugh A HCC in adults who have not received prior checkpoint inhibitor therapy.High risk defined by any of: tumor > 5 cm; > 3 tumors; macrovascular or microvessel invasion on histology; Grade 3/4 histology.

Tecentriq Hybreza may be substituted for IV atezolizumab.

Non-Small Cell Lung Cancer (NSCLC)

NSCLC subsequent therapy: Atezolizumab monotherapy may be used as subsequent therapy for adult members with metastatic or recurrent NSCLC if no prior PD-1/PD-L1 checkpoint inhibitor (e.g., pembrolizumab, nivolumab, durvalumab) has been given and disease progressed during or after platinum-based chemotherapy or after prior EGFR or ALK targeted therapy for EGFR/ALK-positive disease.

NSCLC adjuvant: Adjuvant atezolizumab may be used as monotherapy for adult members with resected stage II–IIIA NSCLC whose tumors have PD-L1 expression ≥1% (tumor cells) following resection and platinum-based chemotherapy; administer up to 16 cycles (approximately 1 year).PD-L1 ≥1% (tumor cell staining)

NSCLC first-line high PD-L1: First-line atezolizumab monotherapy for adult members with metastatic NSCLC negative for EGFR and ALK mutations is allowed when tumors have high PD-L1 expression.PD-L1: TC ≥50% OR IC ≥10%

For first-line non-squamous disease without EGFR/ALK genomic aberrations, combination therapy with bevacizumab (or biosimilar), paclitaxel, and carboplatin is also an allowed first-line option.

Small Cell Lung Cancer (SCLC)

SCLC first-line induction + maintenance: Atezolizumab in combination with etoposide and carboplatin or cisplatin may be used as initial treatment for adult members with extensive-stage small cell lung cancer (ES-SCLC) followed by atezolizumab maintenance for members with complete response, partial response, or stable disease after induction.

This regimen may also be used in second/subsequent line if the member has not received prior checkpoint inhibitor therapy and has not progressed within 6 months of etoposide + platinum therapy.

SCLC maintenance with lurbinectedin: Atezolizumab in combination with lurbinectedin (Zepzelca) may be used for maintenance treatment of adult members with ES-SCLC whose disease has not progressed following four cycles of first-line induction with atezolizumab, carboplatin, and etoposide.

This maintenance regimen with lurbinectedin was added to the policy (policy history).

Urothelial Carcinoma

Urothelial carcinoma: Tecentriq is not supported by Evolent policy for treatment of locally advanced or metastatic urothelial carcinoma in members who are ineligible for cisplatin or any platinum-containing chemotherapy, based on voluntary manufacturer withdrawal after IMvigor130 did not meet the OS co-primary endpoint.

Evolent recommends alternative agents/regimens per Evolent Pathways.

Coverage is not authorized when atezolizumab or Tecentriq Hybreza is being used after disease progression on the same regimen or after progression on a prior anti-PD-1/PD-L1 agent; such requests are exclusionary. The policy also excludes use when dosing exceeds the stated single-dose limits (840 mg IV q2w, 1200 mg IV q3w, 1680 mg IV q4w, or 1875 mg SC q3w). Combination regimens explicitly not supported (e.g., cobimetinib + vemurafenib + atezolizumab in BRAF V600 melanoma) are also excluded. Providers should confirm prior disease course and dosing against these thresholds before submitting authorization requests.

Prescribing information and standard reference sources cited in this guideline should be used to support clinical details included with authorization requests. Key references include the Tecentriq Hybreza prescribing information (Genentech, 2025) and major drug compendia such as Clinical Pharmacology, Micromedex, NCCN Drugs and Biologics Compendium, and AHFS Drug Information (2025).

Tecentriq (atezolizumab) is not supported by this policy for treatment of locally advanced or metastatic urothelial carcinoma in patients who are ineligible for cisplatin or any platinum-containing chemotherapy. This position follows the manufacturer’s voluntary withdrawal related to confirmatory IMvigor130 outcomes; providers should refer to Evolent-recommended alternative regimens when managing platinum-ineligible urothelial carcinoma.

No discrete "not medically necessary" statements beyond the specific exclusions above are included in the excerpted portion of this guideline. Refer to the full policy and referenced prescribing information or compendia for additional coverage or medical necessity determinations when needed.

Regimens and Combinations Supported

Regimen	Indication / Line of therapy	Coverage status
Atezolizumab (Tecentriq) monotherapy
Subsequent therapy for metastatic/recurrent NSCLC if prior anti‑PD‑1/PD‑L1 therapy has not been given; adjuvant therapy for stage II–IIIA NSCLC with PD‑L1 ≥1% (up to 16 cycles); first‑line monotherapy for metastatic NSCLC with high PD‑L1 (TC ≥50% or IC ≥10%).
covered

Regimen	Indication / Rationale	Coverage status
Cotellic (cobimetinib) + Zelboraf (vemurafenib) + Tecentriq (atezolizumab)
Three‑drug regimen for metastatic BRAF V600 mutation–positive malignant melanoma; policy cites IMspire150 updated results showing no overall survival benefit vs cobimetinib + vemurafenib.
not_covered

Regimen (trial or setting)	Study‑based indication / setting	Coverage status
Atezolizumab + bevacizumab (IMbrave150, IMbrave050)
First‑line therapy for unresectable/metastatic hepatocellular carcinoma (Child‑Pugh A) and adjuvant therapy after resection/ablation for high‑risk HCC per cited IMbrave trials.
covered

Line of Therapy Definitions

first-line | second-line

First-line: Atezolizumab may be used as first-line therapy per tumor-specific guidance (see tumor sections) where indicated.

Second-line: Atezolizumab may be used as second-line/subsequent therapy where specified by tumor-specific criteria (e.g., NSCLC subsequent therapy, SCLC second-line when no prior checkpoint inhibitor and no progression within 6 months).

PD-L1 and Other Biomarker Requirements

PD-L1 thresholds — Indications

Adjuvant PD-L1 thresholdTumor PD-L1 ≥1% of tumor cells (TC ≥1%) for adjuvant use in stage II-IIIA NSCLC following resection and platinum chemotherapy.

First-line monotherapy — tumor cellsPD-L1 stained ≥50% of tumor cells (TC ≥50%).

First-line monotherapy — immune cellsPD-L1 stained tumor-infiltrating immune cells covering ≥10% of the tumor area (IC ≥10%).

PD-L1 — Additional notes

Assay contextPD-L1 thresholds apply to tumor PD-L1 immunohistochemistry as specified for NSCLC adjuvant and first-line monotherapy indications.

Use for therapy selectionHigh PD-L1 expression (TC ≥50% or IC ≥10%) is required to consider atezolizumab monotherapy in first-line metastatic NSCLC negative for EGFR/ALK.

Coding, Dose Limits and Billing Rules

HCPCS Codes for atezolizumab formulationsHCPCS

J9022	Injection, atezolizumab, 10 mg
J9024	Injection, atezolizumab, 5 mg and hyaluronidase-tqjs

Single dose IV limits

q2w IV single-dose limitMaximum single IV dose: 840 mg every 2 weeks (q2w).

q3w IV single-dose limitMaximum single IV dose: 1,200 mg every 3 weeks (q3w).

q4w IV single-dose limitMaximum single IV dose: 1,680 mg every 4 weeks (q4w).

Single dose SC limit for Tecentriq Hybreza

SC single-dose limit (Hybreza)Maximum single SC dose: 1,875 mg every 3 weeks (1875 mg q3w) for Tecentriq Hybreza (atezolizumab with hyaluronidase).

Formulation noteTecentriq Hybreza is the subcutaneous formulation of atezolizumab combined with hyaluronidase-tqjs as described in prescribing information.

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required. Evolent processes all medication requests for Tecentriq and Tecentriq Hybreza (atezolizumab IV/SC); medications not authorized by Evolent may be deemed not approvable and not reimbursable.

Evolent is responsible for processing all medication requests from network ordering providers.
Medications not authorized by Evolent may be deemed as not approvable and therefore not reimbursable.

Documentation Required

Prior Authorization Reference Materials

Prescribing information and recognized reference materials must support requests. Use FDA-approved product labeling, CMS-recognized compendia, NCCN or ASCO clinical guidelines, or acceptable peer-reviewed literature.

Tecentriq prescribing information — Genentech, Inc. (2025).

Definitions and Important Terms

Definition of high risk of recurrence (HCC)

Tumor burdenHigh risk of recurrence includes tumor size > 5 cm.

Multifocal diseaseHigh risk of recurrence includes having > 3 tumors.

Vascular invasionHigh risk of recurrence includes macrovascular invasion or microvessel invasion on histology.

High-grade histologyHigh risk of recurrence includes Grade 3 or 4 histology.

Tecentriq Hybreza — SC formulation

DefinitionTecentriq Hybreza is the subcutaneous formulation of atezolizumab combined with hyaluronidase (hyaluronidase-tqjs) as described in the 2025 Genentech prescribing information.

Background

Atezolizumab (Tecentriq) is a programmed death-ligand 1 (PD-L1) immune checkpoint inhibitor indicated across multiple tumor types as monotherapy or in combination with other anticancer agents. It has been studied in indications including hepatocellular carcinoma, non-small cell lung cancer, small cell lung cancer, urothelial carcinoma, and alveolar soft part sarcoma; dosing is available in intravenous and subcutaneous (Tecentriq Hybreza) formulations and the policy references the 2025 prescribing information for formulation-specific administration and substitution guidance.

Revision History and Document Changes

November 2025template_conversion

Converted to new Evolent guideline template and replaced prior UM ONC_1299 Tecentriq policy; multiple indication and substitution updates recorded.

2025added_indication

Updated hepatocellular carcinoma indication to include adjuvant use of atezolizumab plus bevacizumab (or biosimilar) for adults at high risk of recurrence.

2025formulation_substitution

OpenPayer

Tecentriq and Tecentriq Hybreza (atezolizumab IV/SC) — Coverage and Utilization Criteria