Medicare AdvantageDocumentationMedium impact
MA08.165b, Epcoritamab-bysp (EPKINLY®)
Independence Blue Cross·MA · Oncology, Pharmacy·Pharmacy
Effective date
Mar 24, 2025
We identified it
Jun 19, 2026
Summary
Policy MA08.165b establishes medical necessity criteria, coding guidelines, and updated informational requirements for Epcoritamab-bysp (EPKINLY®), a newly covered pharmacy/oncology drug. This policy update affects how claims are coded, what documentation is required to support medical necessity, and billing workflows for this specific therapeutic agent.
Action Required
By March 24, 2025: (1) Billing team must review the complete policy text at the provided URL to identify specific HCPCS/CPT codes for EPKINLY® administration and obtain the detailed medical necessity criteria. (2) Update billing system and prior authorization workflows to reflect any new coding or documentation requirements for this drug. (3) Notify oncology providers and pharmacy staff of the policy effective date and any required documentation changes. (4) Configure system edits to enforce medical necessity documentation before claims are submitted. (5) Train billing staff on the specific criteria that must be met and documented for EPKINLY® claims to avoid denials. Without access to the full policy text, specific code mappings and detailed requirements cannot be confirmed—retrieve the complete policy document immediately.