Medicare AdvantageAdministrativeMedium impact
MA08.047m, Pemetrexed (Pemfexy™)
Independence Blue Cross·MA · Oncology, Pharmacy·Pharmacy
Effective date
Nov 17, 2025
We identified it
Jun 19, 2026
Summary
Policy MA08.047m for Pemetrexed (Pemfexy™) has been updated with changes to medical necessity criteria and medical coding requirements effective 11/17/2025. The billing team must review updated medical necessity documentation requirements and ensure proper coding alignment for all pemetrexed claims submitted to Medicare Advantage plans.
Action Required
By 11/17/2025: Billing team must obtain and review the full policy text from https://medpolicy.ibx.com/ibc/ma/Pages/Site-Activity-View.aspx?FilterField1=MPSiteActivityLogMonth&FilterValue1=11&FilterField2=MPSiteActivityLogYear&FilterValue2=2025#medicare-advantage-ma08-047m-pemetrexed-pemfexy to identify specific medical necessity criteria and coding requirements. Update billing system templates and prior authorization processes to reflect new criteria. Notify oncology providers of documentation requirements needed to support pemetrexed claims. Ensure all claims submitted on or after 11/17/2025 comply with updated medical necessity criteria. Claims submitted without proper documentation per the new criteria may be denied.