CommercialCoverageMedium impact
08.02.05d, Retifanlimab-dlwr (Zynyz®)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
May 4, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross expanded coverage for retifanlimab-dlwr (Zynyz) effective 05/04/2026 by adding appendiceal neoplasms as a new medically necessary indication and revising coverage criteria for anal carcinoma, colon cancer, and Merkel cell carcinoma. Billing teams must update system rules to recognize the new indication and verify claims meet the specific genetic/molecular criteria (dMMR/MSI-H or POLE/POLD1 mutation with TMB >50 mut/Mb) for appendiceal and colon cancer cases.
Action Required
By 05/04/2026: Billing team must update claims processing system to recognize HCPCS code J9345 (Injection, retifanlimab-dlwr, 1 mg) for the newly added appendiceal neoplasm indication. Add system edits to require documentation of genetic/molecular testing results (dMMR/MSI-H or POLE/POLD1 mutation status with TMB >50 mut/Mb) for appendiceal neoplasm and colon cancer claims. Update prior authorization templates and clinical documentation requirements to capture the specific treatment scenarios outlined in the policy (neoadjuvant therapy, metastatic disease, recurrence, etc.). Providers must include appropriate ICD-10 diagnosis codes and molecular testing evidence with claims. Claims lacking required genetic documentation or not meeting the specified treatment scenarios will be denied.