CommercialPrior AuthMedium impact
Tremelimumab-actl (Imjudo®)
BCBS Tennessee·TN · Oncology, Hematology·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
BlueCross BlueShield of Tennessee is establishing a new medical policy for Tremelimumab-actl (Imjudo®) effective September 30, 2026. The policy covers this immunotherapy drug in combination with durvalumab for four cancer indications: unresectable hepatocellular carcinoma, metastatic NSCLC, and esophageal/gastric adenocarcinomas. Prior authorization will be required with specific genetic testing documentation and treatment combination requirements.
Action Required
By September 30, 2026: Billing and clinical teams must implement prior authorization workflows for Tremelimumab-actl (Imjudo®) claims. (1) Update billing system to require prior auth submissions for all four covered indications: unresectable/metastatic HCC, recurrent/advanced/metastatic NSCLC, and esophageal/esophagogastric/gastric adenocarcinomas. (2) Establish documentation requirements in the authorization process: confirmation of genetic testing (EGFR, ALK, RET, ROS1 mutations for NSCLC; MSI-H or dMMR status for GI cancers) and verification that durvalumab is being used in combination therapy. (3) Configure authorization limits in system: HCC indications = 1 month for single dose; NSCLC = 6 months for up to 5 doses; esophageal/gastric cancers = 1 month for single neoadjuvant dose. (4) Train clinical staff and providers on eligibility criteria (e.g., HCC must be unresectable or extrahepatic/metastatic; NSCLC patients must lack sensitizing EGFR mutations/ALK aberrations; GI cancer patients must be medically fit for surgery). (5) Communicate to oncology providers that all other indications outside the four specified are considered experimental/investigational and will not be covered. Claims submitted without prior authorization or missing required genetic testing documentation will be denied.