Medicare AdvantageCoverageMedium impact
MA08.079m, Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)
Independence Blue Cross·Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Sep 22, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross Medicare Advantage policy MA08.079n (effective 09/22/2025) expands daratumumab (Darzalex/Darzalex Faspro) coverage to include new treatment regimens for multiple myeloma variants, relapsed/refractory disease, systemic light chain amyloidosis, smoldering myeloma, and POEMS syndrome. All ICD-10 diagnosis codes have been removed from the policy; billing teams must now report the most appropriate diagnosis code based on the medically necessary criteria listed. This supersedes the previous version MA08.079m.
Action Required
By September 22, 2025: (1) Billing team must update prior authorization workflows to reflect new daratumumab coverage scenarios, including smoldering myeloma, POEMS syndrome, and additional relapsed/refractory disease combinations (Carfilzomib/pomalidomide/dexamethasone and venetoclax for t(11;14)). (2) Update billing software to remove any hardcoded ICD-10 diagnosis codes from daratumumab claims; ensure providers select and report the most appropriate diagnosis code based on the expanded medically necessary criteria. (3) Providers must document which indication from the policy justifies each daratumumab claim (e.g., smoldering myeloma, newly diagnosed with specific combination therapy, relapsed/refractory disease, light chain amyloidosis, POEMS syndrome). (4) Review and update clinical support materials to reflect the new NCCN-preferred regimen including bortezomib/lenalidomide/dexamethasone for transplant-deferred patients. Failure to use correct diagnosis codes or document the appropriate indication will result in claim denials.