Medicare AdvantageCoverageMedium impact
MA08.173, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross·Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Aug 25, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross has published MA08.173b, a new Medicare Advantage policy establishing coverage criteria for tislelizumab-jsgr (Tevimbra®), a PD-1 checkpoint inhibitor immunotherapy. The policy covers the drug for multiple cancer types (anal, appendiceal, CLL/SLL, colon, endometrial, esophageal, gastric, head and neck, nasopharyngeal, hepatocellular, Hodgkin lymphoma, rectal, and small bowel adenocarcinoma) as monotherapy or in combination regimens, subject to specific medical necessity criteria including genetic/mutational status, prior treatment history, and performance scores. Billing teams must implement this coverage policy effective 08/25/2025.
Action Required
By August 25, 2025: Billing and clinical teams must implement the new MA08.173b coverage policy for tislelizumab-jsgr (Tevimbra®) in all systems processing Independence Blue Cross Medicare Advantage claims. Specific actions required: (1) Update billing software and prior authorization protocols to reflect covered indications for the 13 cancer types listed in the policy; (2) Configure system rules to verify medical necessity criteria before claim submission, including documentation of genetic/mutational testing results (dMMR/MSI-H, POLE/POLD1, or TMB status where required), prior immunotherapy history, and applicable performance scores; (3) Train prior authorization and billing staff on the specific criteria for each cancer type (e.g., anal carcinoma requires either second-line monotherapy without prior immunotherapy OR first/primary-line combination therapy with paclitaxel/carboplatin; appendiceal cancer requires ultra-hypermutated phenotype documentation); (4) Update encounter forms and clinical documentation templates to capture required genetic and performance status data; (5) Communicate policy details to oncology providers and practices. Claims submitted without proper medical necessity documentation will be denied. Supersede all prior versions of MA08.173 with this updated MA08.173b guidance.