Medicare AdvantagePrior AuthMedium impact
Tecvayli (teclistamab-cqyv) (Revised)
Humana·FL, KY, SC · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 23, 2026
Summary
Humana revised its Tecvayli (teclistamab-cqyv) prior authorization policy effective July 22, 2026, for Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy maintains two coverage pathways: monotherapy for patients with ≥4 prior therapy lines including specific drug classes, or combination with daratumumab for patients with ≥1 prior line. Billing teams must ensure prior authorization is obtained before dispensing and verify patient eligibility under the specific treatment pathway (monotherapy vs. combination).
Action Required
By July 22, 2026: (1) Billing/Pharmacy team must implement prior authorization requirements in pharmacy dispensing system for Tecvayli (teclistamab-cqyv); (2) Configure system to verify patient meets one of two coverage pathways: either monotherapy with ≥4 prior lines (including anti-CD38 monoclonal antibody, proteasome inhibitor, immunomodulatory agent) OR combination therapy with daratumumab and ≥1 prior line (including proteasome inhibitor and immunomodulatory agent); (3) Add exclusion check to deny coverage if patient has prior disease progression on BCMA-directed CD3 T-cell engager regimen; (4) Verify member eligibility through Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for applicable claim codes; (5) Notify oncology providers and specialty pharmacy partners of the two distinct coverage scenarios to prevent claim denials. Failure to obtain prior authorization will result in claim denials for Tecvayli dispensing.