CommercialPrior AuthHigh impact
Tislelizumab-jsgr (Tevimbra) (CPB 1057, reviewed 2025-12-05)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Dec 5, 2025
We identified it
Aug 18, 2026
Summary
Aetna has issued a new Clinical Policy Bulletin (CPB 1057) effective 2025-12-05 establishing coverage criteria for tislelizumab-jsgr (Tevimbra), a PD-1 inhibitor immunotherapy. The policy covers nine cancer indications (anal, esophageal, gastric, head/neck, hepatocellular, small bowel, colon, appendiceal, and rectal cancers plus histologic Richter transformation) with specific eligibility requirements. All Aetna commercial members require precertification before treatment, and members with prior PD-1/PD-L1 inhibitor progression are excluded from coverage.
Action Required
By 2025-12-05, the billing team must: (1) Implement mandatory precertification workflow for J9329 (tislelizumab-jsgr) for all Aetna commercial plan members before claim submission—contact (866) 752-7021 or fax (888) 267-3277; (2) Update billing system to require supporting documentation of disease stage, PD-L1 expression (≥1 for applicable indications), HER2 status (for gastric/esophageal cancers), microsatellite instability/mismatch repair status (for colorectal/appendiceal/small bowel adenocarcinomas), and prior treatment history; (3) Configure system to deny claims for members with documented prior disease progression on PD-1 or PD-L1 inhibitor therapy; (4) Update oncology encounter forms and prior auth submission templates to capture required clinical data; (5) Train providers and front desk staff on nine covered indications and exclusion criteria; (6) Establish site-of-care verification process per Aetna's specialty drug infusion utilization management policy. Claims submitted without precertification or missing required clinical documentation will be denied.