Medicare AdvantagePrior AuthMedium impact
Tecvayli (teclistamab-cqyv) (Revised)
Humana·KY, SC · Oncology, Pharmacy·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a REVISED Tecvayli (teclistamab-cqyv) prior authorization policy for relapsed/refractory multiple myeloma, updated September 24, 2025. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) and requires prior authorization before dispensing. Key requirements include: patient must have relapsed/refractory multiple myeloma, received at least 4 prior therapy lines (including anti-CD38 monoclonal antibody, proteasome inhibitor, and immunomodulatory agent), and use Tecvayli as a single agent. Exclusion: patients with prior disease progression on BCMA-directed CD3 T-cell engager regimens are not approved.
Action Required
Before dispensing Tecvayli (teclistamab-cqyv): (1) Billing team must verify prior authorization requirements are implemented in pharmacy billing system for Medicare and Medicaid plans in Kentucky and South Carolina. (2) Pharmacy staff must confirm all four prior authorization criteria are met before claim submission: diagnosis of multiple myeloma, relapsed/refractory disease status, documentation of at least 4 prior therapy lines (specifically including anti-CD38 monoclonal antibody, proteasome inhibitor, immunomodulatory agent), and single-agent use. (3) Verify patient is NOT excluded due to prior BCMA-directed CD3 T-cell engager disease progression. (4) Claims submitted without completed prior authorization will be denied. Contact Humana PAL portal (www.humana.com/PAL) for preauthorization and notification list coding information.