Medicare AdvantageCoverageMedium impact
MA08.123e, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
Independence Blue Cross·Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Jul 28, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated MA policy MA08.123e to MA08.123f, effective July 28, 2025, adding coverage for durvalumab (Imfinzi) and tremelimumab-actl (Imjudo) in two new cancer indications (Bladder Cancer and Uterine Neoplasms) and revising coverage criteria for five existing cancer types based on updated NCCN guidelines. ICD-10 diagnosis codes have been removed from the policy as informational only, requiring providers to report the most appropriate diagnosis code supporting medical necessity.
Action Required
By July 28, 2025: Billing team must update coverage criteria documentation for durvalumab (J9173) and tremelimumab-actl (J9347) to include new indications (Bladder Cancer per NCCN V1.2025 and Uterine Neoplasms per NCCN V3.2025) and revised criteria for Ampullary Adenocarcinoma, Biliary Tract Cancers, Hepatocellular Carcinoma, Non-Small Cell Lung Cancer, and Small Cell Lung Cancer. Providers and clinical staff must ensure prior authorization requests include the most appropriate ICD-10 diagnosis code supporting medical necessity criteria, as these codes are no longer listed in the policy. Update EMR templates and prior authorization submission workflows to reference the updated NCCN compendium versions. Without proper diagnosis code documentation, claims will be denied for lack of medical necessity.