CommercialPrior AuthHigh impact
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)
Aetna·Oncology, Pulmonology·Medical Policy
Effective date
Jun 25, 2026
We identified it
Aug 13, 2026
Summary
Aetna has updated its coverage policy for durvalumab (Imfinzi) effective June 25, 2026, establishing specific clinical criteria for approval across 12 cancer indications including NSCLC, SCLC, biliary tract, cervical, colorectal, and other solid tumors. The policy requires precertification for all durvalumab treatment and establishes continuation/reauthorization criteria with defined treatment duration limits. Billing teams must implement prior authorization workflows and ensure claims include genetic/molecular testing documentation as specified in the criteria.
Action Required
By June 25, 2026: Billing team must implement mandatory precertification workflow for all durvalumab (Imfinzi) claims. Update billing system to flag all J9173 charges requiring prior authorization before claim submission. Contact information for precertification: phone (866) 752-7021 or fax (888) 267-3277. Providers must document molecular/genetic testing results (EGFR, ALK, RET, ROS1, MSI-H, dMMR, POLE/POLD1, PD-L1 status as applicable) in all authorization requests and verify patient meets specific cancer stage and treatment combination criteria per policy. Denials will result if precertification is not obtained or if genetic testing documentation is incomplete. Additionally, ensure claims include documentation of site of care per Aetna's Utilization Management Policy on Site of Care for Specialty Drug Infusions. Exclude patients who have experienced disease progression on PD-1 or PD-L1 inhibitors—these are not eligible for coverage.