All PlansPrior AuthMedium impact
Durvalumab (Imfinzi®)
BCBS Tennessee·Oncology, Pulmonology, Hematology·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
This is a new medical policy for Durvalumab (Imfinzi®), an immunotherapy drug covering multiple cancer indications (NSCLC, SCLC, biliary tract, hepatocellular carcinoma, endometrial, bladder, and gastric cancers). The policy establishes coverage criteria, prior authorization requirements, mandatory genetic/biomarker testing documentation, and excludes members with prior PD-1/PD-L1 inhibitor progression. The policy is not effective until October 31, 2026.
Action Required
By October 30, 2026: Billing and prior authorization teams must implement this new medical policy into the authorization system. (1) Create prior authorization requirement for all Durvalumab (Imfinzi®) claims across all covered cancer indications. (2) Configure system to require submission of genetic/biomarker documentation: EGFR mutations (exon 19 deletion and exon 21 L858R), ALK/RET/ROS1 gene fusions, MSI-H/dMMR status, POLE/POLD1 TMB, and PD-L1 expression (where applicable based on indication). (3) Add hard stop in prior authorization workflow to deny claims for members with documented disease progression on prior PD-1 or PD-L1 inhibitor therapy. (4) Train prior authorization staff on the 7 covered cancer indications and specific combination therapy requirements (e.g., tremelimumab combinations, chemotherapy combinations). (5) Update internal policies and provider communication materials. (6) Add approval timeframe rule: grant 6-month authorization periods when criteria are met. Provider education should emphasize that testing documentation is required before claim submission to prevent denials.