CommercialPrior AuthHigh impact
Teclistamab-cqyv (Tecvayli) (CPB 1018, reviewed 2026-06-08)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Jan 10, 2023
We identified it
Aug 17, 2026
Summary
Aetna has updated its coverage policy for Teclistamab-cqyv (Tecvayli), a bispecific antibody for relapsed/refractory multiple myeloma and rare plasma cell disorders. The policy establishes specific approval criteria requiring precertification for all commercial members, with coverage available as monotherapy after 4+ prior therapies or in combination regimens with fewer prior lines. Billing teams must implement mandatory prior authorization workflows and ensure proper coding for this specialty injectable.
Action Required
IMMEDIATE ACTION REQUIRED (Policy is 1 day old): (1) Billing Team: Implement mandatory precertification requirement in billing system for all Tecvayli claims (J9380). Precertification must be obtained BEFORE claim submission by calling (866) 752-7021 or faxing (888) 267-3277. (2) Update billing workflows to require prior auth verification in system before allowing J9380 coding. (3) Providers: Document one of three approval pathways in medical records before requesting precertification: (a) Tecvayli + daratumumab/Darzalex with bortezomib or lenalidomide refractoriness; (b) Tecvayli monotherapy after ≥4 prior therapies including proteasome inhibitor, immunomodulatory agent, AND anti-CD38 monoclonal antibody; or (c) Tecvayli + talquetamab after ≥3 prior therapies. (4) Front desk/intake staff: Route all Tecvayli requests to specialty pharmacy precertification team. (5) Coding staff: Ensure diagnosis codes (C90.00, C90.02, D47.Z9, D47.2) and proper administration codes (96401, 96413-96417) are linked to J9380. CONSEQUENCE: Claims submitted without prior authorization will be denied. This applies to commercial Aetna plans only; refer to separate Medicare Part B criteria for Medicare beneficiaries.