CommercialCoverageHigh impact
08.01.65f, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
Independence Blue Cross·Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Aug 24, 2026
We identified it
Aug 25, 2026
Summary
Independence Blue Cross updated policy 08.01.65f to expand coverage for durvalumab (Imfinzi) and tremelimumab-actl (Imjudo) to include Small Bowel Adenocarcinoma as a new medically necessary indication, and revised coverage criteria for six existing cancer types (Ampullary Adenocarcinoma, Esophageal/Esophagogastric, Gastric, Non-Small Cell Lung, Small Cell Lung, and Uterine Neoplasms) in accordance with NCCN guidelines. The policy also adds new duration of treatment requirements for durvalumab documented in Attachment A.
Action Required
By August 24, 2026: (1) Billing and prior authorization teams must update systems to recognize Small Bowel Adenocarcinoma (ICD-10 C17.9 or specific subsite codes) as a newly covered indication for durvalumab (J9173) and tremelimumab-actl (J9347). (2) Review and update prior authorization requirements for the six revised cancer types to reflect new NCCN-aligned criteria. (3) Obtain and implement Attachment A duration of treatment requirements for durvalumab dosing limits and treatment duration in billing/authorization protocols. (4) Oncology providers and coding staff must ensure claims for these indications include appropriate diagnosis codes and documentation of ECOG performance status where required. (5) Claims submitted before August 24, 2026 using old criteria may be denied on review; verify member eligibility and medical necessity before adjudication.