All PlansPrior AuthHigh impact
Durvalumab (Imfinzi®)
BCBS Tennessee·Oncology, Hematology·Medical Policy
Effective date
Jun 30, 2026
We identified it
Jun 17, 2026
Summary
New comprehensive medical policy for Durvalumab (Imfinzi®) covering multiple cancer indications including lung, biliary tract, hepatocellular, endometrial, bladder, and gastric cancers. Policy establishes prior authorization requirements, coverage criteria, and mandatory genetic testing documentation for various treatment scenarios.
Action Required
By June 30, 2026: Billing team must implement prior authorization requirements for all Durvalumab (Imfinzi®) claims. Update billing system to flag cases requiring genetic testing documentation (EGFR, ALK, RET, ROS1 mutations and MSI-H/dMMR status). Train staff on new coverage criteria for multiple cancer types including NSCLC, SCLC, biliary tract, hepatocellular, endometrial, bladder, and gastric cancers. Update encounter forms to remind oncology providers of required documentation. Claims without proper prior authorization and genetic testing results will be denied.