CurrentAetnaPolicy N/A

TECVAYLI (teclistamab-cqyv) Medication Precertification Request / Coverage Criteria

Customize your policy alerts

Sign up for all Aetna policy alerts

Know when Aetna releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Precertification request form and requirements for Aetna coverage of Tecvayli (teclistamab-cqyv) for treatment of multiple myeloma; used by providers to request initiation or continuation of therapy.

Policy Summary

PayerAetna

PolicyTECVAYLI (teclistamab-cqyv) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrecertification must be requested from Aetna using this notification form (phone or fax) before initiation or continuation of Tecvayli; include documentation of at least four prior therapies including required drug classes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page(s)

4required prior lines

phone

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAetnaPolicy N/A

TECVAYLI (teclistamab-cqyv) Medication Precertification Request / Coverage Criteria

Customize your policy alerts

Sign up for all Aetna policy alerts

Know when Aetna releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Precertification request form and requirements for Aetna coverage of Tecvayli (teclistamab-cqyv) for treatment of multiple myeloma; used by providers to request initiation or continuation of therapy.

Policy Summary

PayerAetna

PolicyTECVAYLI (teclistamab-cqyv) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page(s)

4required prior lines

phone

Coverage Criteria

inv-01: Initiation criteria

Covered when ALL of the following are met

Initial therapy criteria: Patient has a diagnosis of multiple myeloma and the medication will be used in a relapsed or refractory clinical setting (relapsed disease or refractory disease).N/A

Indicate clinical setting on the form

Prior therapies: Patient has received at least four prior therapies for multiple myeloma, including at least one agent from each of the following classes: (A) an anti-CD38 monoclonal antibody (e.g., daratumumab), (B) a proteasome inhibitor (e.g., bortezomib, ixazomib, carfilzomib), and (C) an immunomodulatory agent (e.g., lenalidomide, pomalidomide).>= 4 prior therapies including specified classes

Documentation of prior therapies required on the precertification form

Product information: Requested product, dose, and frequency for Tecvayli (teclistamab-cqyv) are provided on the form.N/A

Complete product information fields (dose and frequency)

inv-02: Continuation criteria

Covered for continuation when ALL of the following are met

Continuation therapy criteria: Provide date of last treatment and indicate whether there is evidence of unacceptable toxicity or disease progression while on the current regimen.N/A

Date of last treatment must be provided on the precertification form

No additional exclusion criteria are specified on the precertification form beyond the requirement to meet the documented prior-therapy conditions. The form’s clinical section focuses on diagnosis, clinical setting (relapsed or refractory), and prior-line therapy documentation rather than listing separate exclusionary conditions.

Requests that do not include documentation showing the patient has received the required prior therapies may be considered not medically necessary. Specifically, the form requires confirmation that the patient has received at least four prior therapies for multiple myeloma including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent; failure to document this history or to complete the required clinical information for initiation or continuation may trigger denial.

Initial Therapy Criteria

inv-14: Initial therapy

Initial therapy requests must document diagnosis, clinical setting, and prior therapies.

Diagnosis and clinical setting: Document diagnosis of multiple myeloma and indicate clinical setting as relapsed or refractory (select appropriate box on the form).N/A

Complete clinical setting fields under G. Clinical Information

Prior therapy documentation: Document that the patient has received at least four prior therapies including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent.>=4 prior therapies including specified classes

List prior therapies on the precertification form

threshold":"N/A","note":"Complete E. Product Information fields","children":[]}

Continuation Therapy Criteria

inv-15: Continuation therapy

Continuation requests require current therapy information and assessment of response/toxicity.

Current therapy information: Provide the date of last treatment and current regimen details for the patient receiving Tecvayli.N/A

Date of last treatment required on the form

Assessment of response/toxicity: Indicate whether there is evidence of unacceptable toxicity or disease progression while on the current regimen (select Yes or No).N/A

Document clinical justification for continuation requests

Coding

Administration codesCPT

Administration code(s) (CPT)

Place to list administration CPT codes as applicable

Diagnosis codesICD-10

Primary ICD Code	Field for primary diagnosis ICD code
Secondary ICD Code	Field for secondary diagnosis ICD code

inv-07: Prior therapy count — >= 4 prior therapies

Minimum prior therapies>= 4 prior therapies

Required drug classesIncludes an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent

Examples of anti-CD38daratumumab (example listed)

Examples of proteasome inhibitorsbortezomib, ixazomib, carfilzomib (examples listed)

Examples of immunomodulatory agentslenalidomide, pomalidomide (examples listed)

Provider Actions & Submission Requirements

Prior Authorization

Precertification required

Precertification must be requested from Aetna using the TECVAYLI Medication Precertification Request (phone or fax) before initiation or for continuation of therapy; include start date for initiation or date of last treatment for continuation and complete all form fields.

Step Therapy

Step/line therapy documentation

Document the patient’s prior therapies and the clinical setting on the form to show the patient meets prior-line (step) requirements before approval; for initiation indicate relapsed or refractory disease and confirm whether the patient has received at least four prior therapies including the specified drug classes.

Indicate clinical setting: relapsed, refractory, or other.
Check Yes/No for having received ≥4 prior therapies and list therapies/classes.

Definitions

inv-13: At least four prior therapies including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent — Prior therapies requirement

Documentation requiredAt least four prior therapies for multiple myeloma must be documented, including one from each specified class

Anti-CD38 monoclonal antibodye.g., daratumumab (must be among prior therapies)

Proteasome inhibitore.g., bortezomib, ixazomib, carfilzomib (must be among prior therapies)

Immunomodulatory agente.g., lenalidomide, pomalidomide (must be among prior therapies)

Background

Tecvayli (teclistamab-cqyv) is requested for treatment of multiple myeloma in relapsed or refractory clinical settings. The precertification form requires completion of the clinical information section for all initiation and continuation requests, including an indication of clinical setting (relapsed or refractory) and confirmation that the patient has received at least four prior therapies, with documentation that those prior therapies include an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent. For continuation requests the form also requires documentation regarding unacceptable toxicity or disease progression on the current regimen.

Step Therapy Requirements

Step	Requirement
1	Document that the patient has received at least four prior therapies for multiple myeloma, including at least one agent from each of the following categories: (A) an anti‑CD38 monoclonal antibody (e.g., daratumumab); (B) a proteasome inhibitor (e.g., bortezomib, ixazomib, carfilzomib); and (C) an immunomodulatory agent (e.g., lenalidomide, pomalidomide).
2	Indicate the clinical setting for which Tecvayli is requested: relapsed disease, refractory disease, or other.
3	For initiation requests, complete all required clinical information on the precertification form to document prior therapies and setting.
4	For continuation requests, provide documentation of date of last treatment and whether there is unacceptable toxicity or disease progression while on the current regimen.

Site of Care & Dispensing

Note

Specify site of care and dispensing provider

Indicate the place of administration and the dispensing provider on the precertification form (self‑administered, physician office, outpatient infusion center, or home infusion) and provide the dispensing provider/pharmacy details.

Select place of administration checkbox on the form
Provide dispensing provider name, address, phone, fax, and TIN/PIN as requested