HCPCS J9022 is officially defined as "Injection, atezolizumab, 10 mg." HCPCS J9022 is referenced in 27 tracked payer policy changes from Sentara Health Plans, Humana, and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J9022 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Humana Medicaid (Ohio) has implemented a new prior authorization policy for Tecentriq (atezolizumab) and Tecentriq Hybreza effective October 1, 2026, covering eight cancer indications with specific clinical criteria. The policy requires prior authorization before dispensing and establishes approval durations of 6 months with renewal options. Multiple exclusions apply, particularly disease progression on prior anti-PD-1/PD-L1 therapy across all indications.
Independence Blue Cross Medicare Advantage added three new medically necessary cancer indications for atezolizumab (Tecentriq) and atezolizumab with hyaluronidase-tqjs (Tecentriq Hybreza): Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma, Colon Cancer, and Thymic Carcinoma. The policy also revised coverage criteria for four existing indications and introduced new duration of treatment requirements in Attachment A, effective August 24, 2026.
Independence Blue Cross updated policy 08.01.69g to expand coverage of atezolizumab (Tecentriq) and atezolizumab with hyaluronidase-tqjs (Tecentriq Hybreza) effective August 24, 2026. Three new cancer indications were added as medically necessary (Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma, Colon Cancer, and Thymic Carcinoma), and criteria were revised for four existing indications. A new attachment on duration of treatment requirements was also added.
Effective July 1, 2026, if a Florida Blue member does not meet the Site of Care criteria for administration at an outpatient hospital facility, an alternative site of care will be required for select oncology immunotherapies used as monotherapy and select non-oncology provider-administered medications. The change applies to new prior authorization requests under the listed Small Group ACA, Individual Under 65 ACA and Large Group Fully Insured products, while members receiving these medications at home, an independent ambulatory infusion center or a professional office are not impacted, and pediatric patients under 18 and patients receiving oncology immunotherapy with chemotherapy are excluded. After a current authorization expires, outpatient hospital administration is covered only when one of the listed criteria is met, and Prime MPS allows one-time temporary authorizations, most often 60 days, at outpatient hospital facilities during the transition.
Anthem is implementing new prior authorization, quantity limit, and step therapy requirements for 8 specialty pharmacy drugs effective June 1, 2026. Billing teams must update systems to require prior authorization for non-oncology specialty drugs managed by Anthem and oncology drugs managed by Carelon, and enforce quantity limits and step therapy edits on specified medications. Patients currently receiving these medications without prior auth may face coverage changes.
Anthem is implementing new prior authorization requirements, quantity limits, and step therapy restrictions for 8 specialty pharmacy drugs effective June 1, 2026. Billing teams must obtain prior authorization for these medications before service dates and include NDC codes on claims to expedite processing. Patients currently receiving these drugs without authorization will require new prior auth requests going forward.
Anthem Blue Cross Blue Shield (Virginia) is implementing new prior authorization, quantity limit, and step therapy requirements for 8 specialty pharmacy drugs effective June 1, 2026. Patients currently receiving these medications without prior authorization will require PA requests going forward. Billing teams must identify these drugs by NDC code and Clinical Criteria document number to route claims appropriately.
Effective June 1, 2026, Anthem Blue Cross Blue Shield (Georgia) is implementing new prior authorization requirements, quantity limits, and step therapy protocols for 8 specialty pharmacy medications. Billing teams must begin requesting prior authorization for these drugs on all dates of service on or after June 1, 2026, and include NDC codes on claims to expedite processing. Oncology-use prior authorizations will be managed by Carelon Medical Benefits Management rather than Anthem's standard review team.
Premera HMO plans in Washington have changes from the October 2025 medical policy and coding update. Dated items include the Abdominal Wall Hernia policy and its codes effective January 2, 2026, advanced imaging site-of-care review through Carelon and a Washington mandate for medical clearance of minors' hearing aid coverage effective January 1, 2026, and Federal Employee Program prior authorization for hip, knee and spine surgery effective January 1, 2026. Several biologic and drug policies also moved products between preferred and non-preferred status.
Premera HMO plans in Washington have changes from the September 2025 medical policy and coding update. The lead item is advanced imaging site-of-care review through Carelon Medical Benefits Management, Inc., effective January 1, 2026 for dates of service on and after that date. Many coded services also now require review for medical necessity and prior authorization, including negative pressure wound therapy, oncology drugs, percutaneous coronary intervention and selected ASC surgical procedures.
Beginning January 1, 2026, the procedure codes in this Centene bulletin require prior authorization through Evolent, which manages prior authorizations for Centene in medical oncology, radiation oncology, pediatric and dose optimization, and cardiology. The change applies to all Ambetter (Marketplace), Medicaid and Medicare products offered by Centene. The code table includes anti-emetics, bone metastasis drugs, cancer treatment drugs, and supportive medications such as iron products, ESAs, myeloid growth factors and immune globulins.
Effective October 3, 2025, codes for several drugs, including J0491, J0517, J0638, J2182, J2351, J2356, J2357, J3032, J3111, J3241, J9024, J9272, J9332 and J9334, now require review for site of service, in addition to the existing medical necessity and prior authorization review. Physical and occupational therapy services for individual plans require prior authorization starting with the seventh visit, effective July 3, 2025. Effective September 5, 2025, non-individual plans use InterQual criteria to determine the appropriate level of care for all planned procedures.
Effective January 1, 2026, site of service is reviewed for advanced imaging services under Carelon Medical Benefits Management's Site of Care for Advanced Imaging criteria, and hospital outpatient site of care is considered medically necessary when ancillary services are required and not available at freestanding centers in the same geographic area. Effective November 7, 2025, bariatric surgery reoperation for inadequate weight loss is considered medically necessary if the original procedure fails, such as unsuccessful band adjustments, resulting in less than 50% excess weight loss or less than 20% total weight loss. Effective November 7, 2025, select surgical procedures previously reviewed for site of service in the inpatient setting are reviewed for site of service in the ambulatory surgical center setting under policy 11.01.525.
Independence Blue Cross updated MA08.127f to MA08.127g effective 08/25/2025, revising coverage criteria for atezolizumab (Tecentriq) and atezolizumab with hyaluronidase-tqjs (Tecentriq Hybreza) to align with updated NCCN guidelines across multiple cancer types. All ICD-10 diagnosis codes were removed from the policy (providers must now report appropriate diagnosis codes independently), and Attachment A was removed as informational only.
Independence Blue Cross updated policy 08.01.69f to version 08.01.69g, revising atezolizumab coverage criteria to align with updated NCCN guidelines across multiple cancer types (cervical, hepatocellular carcinoma, melanoma, non-small cell lung cancer, and soft tissue sarcoma). All ICD-10 diagnosis codes were removed from the policy; billing teams must now report the most appropriate diagnosis code that supports medical necessity criteria.
Aetna covers enfortumab vedotin-ejfv (Padcev) for commercial medical plans, and precertification of Padcev is required for Aetna participating providers and members in applicable plan designs. Aetna considers Padcev medically necessary for urothelial carcinoma when criteria are met, including as a single agent used as subsequent therapy after platinum-containing chemotherapy and prior PD-1 or PD-L1 inhibitor treatment, or as subsequent therapy for members ineligible for cisplatin-containing chemotherapy, and in combination with pembrolizumab or pembrolizumab and berahyaluronidase alfa-pmph for stage II, recurrent, locally advanced, or metastatic urothelial carcinoma. Aetna considers all other indications experimental, investigational, or unproven.
Aetna considers avelumab (Bavencio) medically necessary for commercial plan members with Merkel cell carcinoma, renal cell carcinoma in combination with axitinib, urothelial carcinomas, gestational trophoblastic neoplasia, endometrial carcinoma, thymic carcinoma, extranodal NK/T-cell lymphoma, colorectal adenocarcinoma, and small bowel adenocarcinoma when the criteria for each indication are met. Precertification of avelumab is required for all Aetna participating providers and members in applicable plan designs, and members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible. Aetna considers avelumab experimental, investigational, or unproven for all other indications, including breast cancer, non-small cell lung cancer, ovarian cancer, prostate cancer, and pancreatic cancer.
Aetna covers Prolia and its ten listed biosimilars, and Xgeva and its nine listed biosimilars, under commercial medical plans, and precertification is required for these denosumab products in applicable plan designs. Prolia is considered medically necessary for postmenopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, bone loss in men receiving androgen deprivation therapy for prostate cancer, bone loss in women receiving adjuvant aromatase inhibitor therapy for breast cancer, and inhibiting progression of bone erosion in rheumatoid arthritis, based on criteria such as fragility fracture history, pre-treatment T-score, pre-treatment FRAX probability, and prior therapy response or intolerance. Xgeva is considered medically necessary for multiple myeloma, bone metastases from solid tumors, giant cell tumor of bone, hypercalcemia of malignancy refractory to intravenous bisphosphonate therapy, and second-line therapy for osteopenia or osteoporosis in systemic mastocytosis, and continuation of Xgeva requires disease stability or improvement.
Aetna's commercial policy for atezolizumab (Tecentriq) and atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) requires precertification from all Aetna participating providers and members in applicable plan designs, and the Site of Care Utilization Management Policy applies to both products. Coverage is limited to the listed indications and their stated criteria, including non-small cell lung cancer, small cell lung cancer, hepatocellular carcinoma, melanoma, colon and rectal cancer, and muscle invasive bladder cancer after cystectomy when the member is positive for ctDNA MRD. Members who have progressed on PD-1 or PD-L1 inhibitor therapy are not eligible, and Aetna considers all other indications experimental, investigational, or unproven.
Aetna Clinical Policy Bulletin 1057 sets the commercial medical coverage criteria for tislelizumab-jsgr (Tevimbra). Aetna considers it medically necessary for several cancers under indication-specific criteria, including subsequent treatment of metastatic anal carcinoma, esophageal and esophagogastric junction cancer, HER2-negative gastric adenocarcinoma, metastatic nasopharyngeal cancer, hepatocellular carcinoma, and histologic (Richter) transformation to diffuse large B-cell lymphoma. It also covers MSI-H, dMMR, or POLE/POLD1 ultra-hypermutated small bowel, colon, appendiceal, and rectal adenocarcinomas under the stated criteria, and considers all other indications experimental, investigational, or unproven.
Aetna considers lurbinectedin (Zepzelca) medically necessary for small cell lung cancer in these regimens: as a single agent for subsequent treatment after relapse, primary progressive disease, or metastatic disease that progressed on or after platinum-based chemotherapy; or in combination with atezolizumab or atezolizumab and hyaluronidase-tqjs as maintenance treatment for extensive stage disease when there is no progression after first-line induction with atezolizumab or atezolizumab and hyaluronidase-tqjs, carboplatin and etoposide. Aetna considers lurbinectedin experimental, investigational, or unproven for breast cancer, endometrial cancer, macular edema, neuroendocrine carcinoma, non-small cell lung cancer and ovarian cancer.
Aetna requires precertification for ramucirumab (Cyramza) for all participating providers and members in applicable commercial plan designs. Aetna considers ramucirumab medically necessary for gastric, gastro-esophageal junction, and esophageal adenocarcinoma in members who are not surgical candidates or have unresectable locally advanced, recurrent or metastatic disease, and for NSCLC, advanced colorectal cancer with FOLFIRI or irinotecan, hepatocellular carcinoma with AFP of at least 400 ng/mL, mesothelioma with gemcitabine, and thymic carcinoma in the specified carboplatin and paclitaxel settings. Aetna considers ramucirumab experimental, investigational, or unproven for other indications, including breast, ovarian, prostate and renal cell cancers, head and neck cancer, melanoma and rheumatoid arthritis.
Aetna Clinical Policy Bulletin 0967 covers enfortumab vedotin-ejfv (Padcev) for commercial medical plans and requires precertification for all Aetna participating providers and members in applicable plan designs. Aetna considers Padcev medically necessary for urothelial carcinoma as a single agent when it is used as subsequent therapy after platinum-containing chemotherapy and a PD-1 or PD-L1 inhibitor, or as subsequent therapy for members who are ineligible for cisplatin-containing chemotherapy, in the listed bladder, upper genitourinary tract, and prostate settings, and in combination with pembrolizumab or pembrolizumab and berahyaluronidase alfa-pmph for stage II, recurrent, locally advanced, or metastatic urothelial carcinoma. Aetna considers all other indications experimental, investigational, or unproven.
Aetna considers durvalumab (Imfinzi) medically necessary for commercial medical plans when the criteria for a listed indication are met, and considers all other indications experimental, investigational, or unproven. Precertification is required of all Aetna participating providers and members in applicable plan designs, and Aetna considers members not eligible for Imfinzi when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy. Continuation of therapy is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen, up to 12 months total for unresectable stage II or III NSCLC and up to 24 months total for limited stage SCLC.
Aetna's criteria cover avelumab (Bavencio) for Merkel cell carcinoma as a single agent; first-line advanced renal cell carcinoma with clear cell histology in combination with axitinib; urothelial carcinomas (bladder cancer, primary carcinoma of the urethra, upper genitourinary tract tumors, and urothelial carcinoma of the prostate) as subsequent therapy or as maintenance therapy when there is no progression on first-line platinum-containing chemotherapy; gestational trophoblastic neoplasia; recurrent endometrial carcinoma (as a single agent when MSI-H or dMMR, or with axitinib when pMMR); thymic carcinoma with axitinib; relapsed or refractory extranodal NK/T-cell lymphoma; and colorectal or small bowel adenocarcinoma that is dMMR/MSI-H or POLE/POLD1 ultra-hypermutated, as a single agent or as neoadjuvant treatment of up to 6 months. Members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible, and all other indications are considered experimental, investigational or unproven. This policy addresses avelumab for commercial medical plans, where precertification is required and the Site of Care Utilization Management Policy applies.
Aetna's commercial coverage policy for atezolizumab (Tecentriq) and atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) covers them for specific indications when the criteria are met. Covered indications include recurrent, advanced or metastatic non-small cell lung cancer, extensive-stage small cell lung cancer, hepatocellular carcinoma in combination with bevacizumab, BRAF V600 mutation-positive melanoma in combination with cobimetinib and vemurafenib, alveolar soft part sarcoma, and adjuvant treatment of muscle invasive bladder cancer after cystectomy when the member is positive for circulating tumor DNA molecular residual disease. Precertification is required in applicable plan designs, and the Site of Care Utilization Management Policy applies. Use for all other indications is considered experimental, investigational, or unproven, and members are not eligible after disease progression on PD-1 or PD-L1 inhibitor therapy.
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