CommercialPrior AuthMedium impact
Amivantamab-vmjw (Rybrevant™)
BCBS Tennessee·TN · Oncology, Internal Medicine·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
BlueCross BlueShield of Tennessee is introducing a new medical policy for Amivantamab-vmjw (Rybrevant™), an oncology drug for non-small cell lung cancer (NSCLC) with specific EGFR mutations. The policy establishes coverage criteria, prior authorization requirements, and documentation standards for this newly approved combination therapy. Implementation is delayed until December 1, 2026.
Action Required
By November 15, 2026: Billing and clinical teams must review and implement the Amivantamab (Rybrevant™) prior authorization policy. Specific requirements: (1) Update billing system to flag Rybrevant claims for prior authorization; (2) Create prior auth submission checklist requiring EGFR mutation test results (exon 19 deletion, exon 21 L858R substitution, or exon 20 insertion mutations per FDA-approved testing); (3) Train providers and billing staff on covered indications—first-line treatment with lazertinib, subsequent treatment following EGFR TKI progression, brain metastases treatment, and exon 20 insertion mutations; (4) Configure system to grant 12-month authorization periods for initial therapy and reauthorization when no unacceptable toxicity or disease progression occurs; (5) Ensure encounter forms capture combination therapy details (lazertinib, carboplatin/pemetrexed, or single-agent use). Billing team must require EGFR mutation documentation before claim submission. Failure to obtain prior authorization will result in claim denials for Tennessee BlueCross BlueShield members.