Medicare AdvantagePrior AuthMedium impact
MA08.161c, Retifanlimab-dlwr (Zynyz®)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
Jul 1, 2025
We identified it
Jun 19, 2026
Summary
Policy MA08.161c establishes medical necessity criteria for Retifanlimab-dlwr (Zynyz®), a PD-L1 inhibitor immunotherapy. This is a new pharmacy policy for Medicare Advantage plans effective July 1, 2025. The billing team must implement prior authorization and medical necessity documentation requirements before this date to ensure claims are processed without denial.
Action Required
By June 30, 2025: Billing team must update claims system to require prior authorization for HCPCS code J9829 (Retifanlimab-dlwr injection) on all Medicare Advantage claims. Coordinate with providers and clinical staff to ensure medical necessity documentation (including diagnosis, treatment history, and clinical indication for PD-L1 inhibitor therapy) is attached to all authorization requests. Update pharmacy and oncology encounter templates to capture required clinical data. Flag all claims for J9829 submitted without prior auth approval for manual review. Communicate new requirements to all providers ordering this drug. Claims submitted without proper authorization and documentation will be denied.