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TECVAYLI (teclistamab-cqyv) Medication Precertification Request / Coverage Criteria
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Initiation criteria
Covered when ALL of the following are met
Indicate clinical setting on the form
Documentation of prior therapies required on the precertification form
Complete product information fields (dose and frequency)
inv-02: Continuation criteria
Covered for continuation when ALL of the following are met
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.
Complete clinical setting fields under G. Clinical Information
List prior therapies on the precertification form
Continuation Therapy Criteria
inv-15: Continuation therapy
Continuation requests require current therapy information and assessment of response/toxicity.
Date of last treatment required on the form
Document clinical justification for continuation requests
Coding
| Administration code(s) (CPT) | Place to list administration CPT codes as applicable |
| Primary ICD Code | Field for primary diagnosis ICD code |
| Secondary ICD Code | Field for secondary diagnosis ICD code |
Provider Actions & Submission Requirements
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/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.
Required submission documents
Submit a completed precertification request form with patient, prescriber, and dispensing/administration information; include product name, dose and frequency, primary and secondary ICD codes, and all required clinical information (prior therapies and setting).
- Patient and prescriber contact information and precertification requested by details.
- Place of administration / dispensing provider indicated (self-administered, physician office, outpatient infusion, home).
- Product: Tecvayli (teclistamab-cqyv) — dose and frequency fields must be completed.
- Primary and secondary ICD codes must be specified.
- For initiation/continuation, complete required clinical information fields (including prior therapies and dates).
Prior therapy requirement — denial risk
Failure to document 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, may trigger denial of the request.
- Form requires a Yes/No response to the question about ≥4 prior therapies and the three specified classes.
- Lack of this documentation may render the request not medically necessary.
Definitions
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
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
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