CommercialPrior AuthMedium impact
Ipilimumab (Yervoy®)
BCBS Tennessee·TN · Oncology, Hematology·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
BlueCross BlueShield of Tennessee has released a comprehensive medical policy for Ipilimumab (Yervoy®) covering multiple cancer indications with specific prior authorization requirements, documentation standards, and coverage criteria. This policy is not effective until 9/30/2026 and establishes coverage for FDA-approved indications (melanoma, RCC, CRC, HCC, NSCLC, mesothelioma, esophageal cancer) plus compendial uses across numerous other cancer types.
Action Required
Before 9/30/2026: Billing and prior authorization teams must review and prepare for implementation of this Ipilimumab policy. Specific preparation steps: (1) Update prior authorization workflows to require MSI-H/dMMR/POLE-POLD1 tumor status documentation for applicable indications; (2) Create system rules requiring documentation of EGFR, ALK, RET, and ROS1 gene fusion testing results where applicable; (3) Configure authorization limits to 6-month periods for compendial uses and specific dosing protocols (e.g., 4-dose cycles followed by nivolumab monotherapy for certain indications); (4) Train prior authorization staff on the distinction between FDA-approved indications (which require standard approval criteria) and compendial uses (which require specific molecular/mutation documentation); (5) Implement denial prevention by ensuring providers include required biomarker testing documentation with all Ipilimumab requests; (6) Coordinate with oncology practices to confirm they understand documentation requirements before the effective date. Claims submitted without proper authorization or required documentation will be denied.