CommercialCoverageMedium impact
08.01.90b, Amivantamab-vmjw (Rybrevant®)
Independence Blue Cross·PA · Oncology, Pharmacy, Pulmonology·Pharmacy
Effective date
Jul 28, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.01.90b to 08.01.90d, effective 07/28/2025, expanding coverage for amivantamab (Rybrevant/Rybrevant Faspro) to include first-line combination therapy with lazertinib for EGFR exon 19 deletion/L858R mutations, subsequent therapy following EGFR TKI progression, and continuation therapy for limited disease progression. ICD-10 diagnosis codes are no longer listed in the policy; billing teams must report the most appropriate diagnosis code supporting medical necessity.
Action Required
By 07/28/2025: Billing and clinical teams must update prior authorization workflows and clinical decision support systems to reflect expanded coverage criteria for amivantamab (J9061, J9062). Specifically: (1) Implement prior auth approval for first-line amivantamab + lazertinib combination for EGFR exon 19 deletion or L858R NSCLC; (2) Update auth protocols to include subsequent therapy scenarios following EGFR TKI progression; (3) Add continuation therapy criteria (asymptomatic disease, symptomatic brain lesions, or symptomatic systemic limited progression) to approval logic; (4) Remove reliance on ICD-10 codes from policy documents—instead train providers and coders to report the most appropriate diagnosis code supporting documented medical necessity in each case. Update encounter forms and prior auth request templates to include mutation type (exon 19 deletion or L858R) as required supporting documentation. Notify providers of the new first-line combination indication to prevent claim denials for previously non-covered scenarios.