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Durvalumab (Imfinzi®)
BCBS Tennessee·Oncology, Pulmonology, Hematology +2 more·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
This is a new medical policy establishing coverage criteria and prior authorization requirements for Durvalumab (Imfinzi®) across multiple cancer indications including NSCLC, SCLC, biliary tract, hepatocellular carcinoma, endometrial, bladder, and gastric cancers. The policy specifies required genetic/molecular testing documentation, treatment combinations, disease stages, and 6-month authorization periods. CRITICAL: This policy is marked 'Do Not Implement until 9/30/26' and is not yet effective.
Action Required
By September 29, 2026: Billing and clinical teams must implement this policy in all billing and prior authorization systems. (1) Update prior authorization workflows to require submission of specific documentation: EGFR/ALK/RET/ROS1 mutation status, MSI-H/dMMR/POLE-POLD1 tumor status, and PD-L1 expression where applicable. (2) Configure system to apply 6-month authorization limits for NSCLC, SCLC, BTC, and HCC indications; 3-month authorization (3 doses) for gastric/GEJ/esophageal adenocarcinoma. (3) Add exclusion rule: deny coverage for members with prior PD-1/PD-L1 inhibitor disease progression. (4) Train billing staff on covered indications (FDA-approved and compendial uses listed) versus experimental/investigational uses. (5) Update encounter forms and prior auth request templates to capture required molecular testing results and treatment regimen details. (6) Providers must submit complete genetic testing documentation or justify why testing is not feasible; claims will be denied without proper prior authorization and documentation. MONITOR: This policy has a future effective date; validate implementation readiness by September 15, 2026.