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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsPremera Bispecific Drug Prior Auth | OpenPayer
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    ModifiedPremera Blue Cross of WashingtonPolicy 5.01.650

    Bispecific Antibody Drug Coverage

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    This policy governs medical-necessity review and prior authorization for selected bispecific antibody drugs used to treat cancer. The drugs are managed through the medical benefit and apply to providers submitting coverage requests for eligible individuals.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyBispecific Antibody Drug Coverage
    Policy CodePolicy 5.01.650
    Change TypeModified
    Effective DateNov 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateNot specified
    Key ActionSubmit office visit notes documenting the diagnosis, relevant history, physical evaluation, medication history, and applicable medical-necessity criteria.
    SourceLink

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    POLICY UPDATE CHANGES

    Coverage criteria were added for Bizengri (zenocutuzumab-zbco) and Ziihera (zanidatamab-hrii).

    Blincyto (blinatumomab) criteria were expanded to include standard- or high-risk B-cell acute lymphoblastic leukemia in pediatric individuals.

    Coverage criteria were updated for Epkinly, Bizengri, Ziihera, Lunsumio Velo, Rybrevant Faspro, Rybrevant, Imdelltra, and Tecvayli to address new indications or clarify treatment requirements.

    Coverage criteria were added for adult individuals with advanced, unresectable, or metastatic cholangiocarcinoma harboring an NRG1 gene fusion after progression on prior systemic therapy.

    Ziihera criteria were added for HER2-positive unresectable, locally advanced, or metastatic gastric, gastroesophageal junction, or esophageal adenocarcinoma.

    HCPCS codes J9276 and J9382 were added for Ziihera and Bizengri, respectively, and additional HCPCS codes were added through coding updates.

    14Bispecific antibody drugs with listed HCPCS codes
    6 monthsMaximum initial authorization period
    12 monthsMaximum reauthorization period
    Medical benefitBenefit under which listed drugs are managed
    InvestigationalNoncriteria or unlisted uses

    Coverage Criteria

    Bizengri initial therapy

    Covered when all of the following are met.

    Bizengri eligibility

    • Eligible diagnosis: Advanced, unresectable, or metastatic pancreatic adenocarcinoma; advanced, unresectable, or metastatic NSCLC; or advanced, unresectable, or metastatic cholangiocarcinoma.

    Blincyto initial therapy

    Covered when all of the following are met.

    Blincyto eligibility

    • Eligible diagnosis or treatment phase: CD19-positive B-cell precursor ALL in first or second complete remission with MRD greater than or equal to 0.1%; relapsed or refractory CD19-positive B-cell precursor ALL; CD19-positive B-cell precursor ALL in the consolidation phase; or standard- or high-risk B-cell ALL in an individual younger than 18 years.

    Columvi initial therapy

    Covered when all of the following are met.

    Columvi eligibility: The individual is aged 18 years or older; has relapsed or refractory DLBCL, NOS, or LBCL arising from follicular lymphoma; has had an inadequate response to 2 or more lines of systemic therapy; and has documentation of pretreatment with a single 1,000 mg intravenous dose of obinutuzumab 7 days before Columvi initiation.At least 2 prior systemic-therapy lines; obinutuzumab 1,000 mg IV 7 days before initiation

    Elrexfio initial therapy

    Covered when all of the following are met.

    Elrexfio eligibility: The individual is aged 18 years or older; has relapsed or refractory multiple myeloma; and has received at least 4 prior lines of therapy including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.At least 4 prior lines

    Examples include bortezomib, carfilzomib, or ixazomib; lenalidomide, pomalidomide, or thalidomide; and daratumumab or isatuximab-irfc.

    Epkinly for DLBCL

    Covered when all of the following are met.

    Epkinly DLBCL eligibility: The individual is aged 18 years or older; has relapsed or refractory DLBCL, NOS, including DLBCL arising from indolent lymphoma, or high-grade B-cell lymphoma; and has received 2 or more lines of systemic therapy.At least 2 prior systemic-therapy lines

    Epkinly for follicular lymphoma

    Covered when all of the following are met.

    Epkinly follicular lymphoma eligibility

    • Treatment approach: Epkinly is used in combination with lenalidomide and rituximab, or Epkinly is used as monotherapy after 2 or more lines of systemic therapy.At least 2 prior systemic-therapy lines for monotherapy

    Imdelltra initial therapy

    Covered when all of the following are met.

    Imdelltra eligibility: The individual is aged 18 years or older; has relapsed or refractory extensive-stage small cell lung cancer; has progressed on or after platinum-based chemotherapy, such as cisplatin or carboplatin; and Imdelltra is prescribed by or in consultation with an oncologist.Progression on or after platinum-based chemotherapy

    Lynozyfic initial therapy

    Covered when all of the following are met.

    Lynozyfic eligibility: The individual is aged 18 years or older; has relapsed or refractory multiple myeloma; and has received at least 4 prior lines of therapy including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.At least 4 prior lines

    Examples include bortezomib, carfilzomib, or ixazomib; lenalidomide, pomalidomide, or thalidomide; and daratumumab or isatuximab-irfc.

    Lunsumio and Lunsumio Velo initial therapy

    Covered when all of the following are met.

    Lunsumio eligibility: The individual is aged 18 years or older; has relapsed or refractory follicular lymphoma; and has had an inadequate response or intolerance to 2 or more lines of systemic therapy.At least 2 prior systemic-therapy lines

    Applies to Lunsumio IV and Lunsumio Velo SC.

    Rybrevant for EGFR exon 20 insertion NSCLC

    Covered when all of the following are met.

    Rybrevant EGFR exon 20 eligibility

    • Treatment setting: Disease has progressed on or after platinum-based chemotherapy and Rybrevant is given as a single agent, or Rybrevant is first-line treatment used in combination with carboplatin and pemetrexed.

    Rybrevant and Rybrevant Faspro for EGFR exon 19/L858R NSCLC

    Covered when all of the following are met.

    Rybrevant or Rybrevant Faspro EGFR exon 19/L858R eligibility

    • Treatment setting: Disease has progressed on or after treatment with an EGFR tyrosine kinase inhibitor and the drug is used with carboplatin and pemetrexed, or the drug is used as first-line treatment in combination with Lazcluze.

    Rybrevant Faspro for EGFR exon 20 insertion NSCLC

    Covered when all of the following are met.

    Rybrevant Faspro EGFR exon 20 eligibility

    • Treatment setting: Disease has progressed on or after platinum-based chemotherapy and Rybrevant Faspro is used as a single agent, or Rybrevant Faspro is first-line treatment used in combination with carboplatin and pemetrexed.

    Talvey initial therapy

    Covered when all of the following are met.

    Talvey eligibility: The individual is aged 18 years or older; has relapsed or refractory multiple myeloma; and has received at least 4 prior lines of therapy including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.At least 4 prior lines

    Examples include bortezomib, carfilzomib, or ixazomib; lenalidomide, pomalidomide, or thalidomide; and daratumumab or isatuximab-irfc.

    Tecvayli initial therapy

    Covered when all of the following are met.

    Tecvayli eligibility

    • Treatment pathway: At least 1 prior line including a proteasome inhibitor and immunomodulatory agent, with Tecvayli combined with daratumumab hyaluronidase-fihj; or at least 4 prior lines including a proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody, with Tecvayli as monotherapy.At least 1 prior line for combination therapy; at least 4 prior lines for monotherapy

    Ziihera for biliary tract cancer

    Covered when all of the following are met.

    Ziihera biliary tract cancer eligibility: The individual is aged 18 years or older; has unresectable or metastatic HER2-positive biliary tract cancer with IHC 3+ or ISH+ status; has been previously treated; Ziihera is administered as monotherapy; Ziihera is prescribed by or in consultation with an oncologist; and the dose is limited to 20 mg/kg every 2 weeks.20 mg/kg every 2 weeks

    Ziihera for gastric, gastroesophageal junction, or esophageal adenocarcinoma

    Covered when all of the following are met.

    Ziihera gastric, gastroesophageal junction, or esophageal adenocarcinoma eligibility

    • HER2 treatment pathway: For IHC 3+, Ziihera is used with fluoropyrimidine- and platinum-containing chemotherapy; or for IHC 3+ or IHC 2+/ISH+, Ziihera is used with fluoropyrimidine- and platinum-containing chemotherapy and tislelizumab-jsgr.

    Use of Rybrevant (amivantamab-vmjw) for solid tumors or hematologic malignancies not specifically listed in this policy is considered investigational.

    All other uses of the medications listed in this policy are considered investigational. Coverage is limited to the indications and requirements described in the policy and the product’s FDA-approved dosage and administration information.

    Coding and Dose Information

    HCPCSHCPCS
    C9307Injection, linvoseltamab-gcpt, 1 mg (code termed 04/01/26)
    J1323Injection, elranatamab-bcmm (Elrexfio), 1 mg
    J3055Injection, talquetamab-tgvs (Talvey), 0.25 mg
    J9026Injection, tarlatamab-dlle (Imdelltra), 1 mg
    J9039Injection, blinatumomab (Blincyto), 1 mcg
    J9061Injection, amivantamab-vmjw (Rybrevant), 2 mg
    J9062Injection, amivantamab 5 mg and hyaluronidase-lpuj (Rybrevant Faspro) (new code effective 07/01/26)
    J9276Injection, zanidatamab-hrii (Ziihera), 2 mg
    J9286Injection, glofitamab-gxbm (Columvi), 2.5 mg
    J9321Injection, epcoritamab-bysp (Epkinly), 0.16 mg
    1–10 of 14
    1/2
    HCPCS codes addedHCPCS
    J1323HCPCS code added
    J3055HCPCS code added
    J9026HCPCS code added
    J9039HCPCS code added
    J9061HCPCS code added
    J9286HCPCS code added
    J9321HCPCS code added
    J9350HCPCS code added
    J9380HCPCS code added
    J9999HCPCS code added in the original coding update
    Subsequent HCPCS coding updatesHCPCS
    J9276Ziihera (zanidatamab-hrii)
    J9382Bizengri (zenocutuzumab-zbco)
    C9307HCPCS code later terminated
    J9601HCPCS code added
    HCPCS codes removed or updatedHCPCSNot Covered
    J9062HCPCS code added
    J9999HCPCS code removed
    Blincyto minimum residual disease
    ThresholdMRD greater than or equal to 0.1%
    DiseaseCD19-positive B-cell precursor acute lymphoblastic leukemia (ALL)
    Applicable settingFirst or second complete remission
    Bizengri dose
    DrugBizengri (zenocutuzumab-zbco)
    Dose750 mg
    Frequency

    Authorization and Documentation Requirements

    Prior Authorization

    Initial Authorization Period

    Initial authorization for all drugs listed in the policy may be approved for up to 6 months.

    Prior Authorization

    Reauthorization Period

    Reauthorization for all drugs listed in the policy may be approved for up to 12 months when the applicable drug-specific coverage criteria continue to be met.

    Billing Rule

    Medical-Benefit Management

    The drugs listed in this policy are managed through the medical benefit.

    Policy Background

    Bispecific antibody drugs are immunotherapies that engage the immune system to help identify and kill cancer cells. This policy addresses selected bispecific antibody drugs used for specified hematologic malignancies and solid tumors when applicable diagnosis, age, biomarker, prior-treatment, combination-therapy, dosing, and response requirements are satisfied. The drugs are reviewed for medical necessity and managed through the medical benefit.

    Definitions

    Bispecific antibody drugs
    Drug classBispecific antibody drugs
    Therapeutic typeImmunotherapy drugs
    FunctionStrengthen the immune system so immune cells can find and kill cancer cells more effectively
    Age limits
    Policy applicationAge limits specified in this policy
    BasisFDA-approved indications
    ApplicabilityWhere applicable

    Initial Therapy Criteria

    Bizengri

    Bizengri may be considered medically necessary when all criteria are met.

    Bizengri: Age at least 18 years; eligible advanced, unresectable, or metastatic pancreatic adenocarcinoma, NSCLC, or cholangiocarcinoma; NRG1 gene fusion; monotherapy; progression on or after prior systemic therapy; and dose limited to 750 mg every 2 weeks.750 mg every 2 weeks

    Blincyto

    Blincyto may be considered medically necessary when all criteria are met.

    Blincyto: Age at least 1 month and an eligible CD19-positive B-cell precursor ALL indication: first or second complete remission with MRD greater than or equal to 0.1%; relapsed or refractory disease; consolidation phase; or standard- or high-risk B-cell ALL in an individual younger than 18 years.MRD greater than or equal to 0.1% where applicable

    Continuation and Reauthorization Criteria

    All listed drugs

    Reauthorization may be approved when all of the following are met.

    Continuation authorization: The drug-specific coverage criteria continue to be met and chart notes demonstrate that the individual continues to show a positive clinical response to therapy.Up to 12 months

    Applies to all drugs listed in the policy.

    Prior Treatment Requirements

    MedicationPrior-treatment requirementCoverage
    BizengriDisease progression on or after prior systemic therapy.Covered
    MedicationPrior-treatment requirementCoverage
    ColumviInadequate response to 2 or more lines of systemic therapy. Pretreatment with a single 1,000 mg intravenous dose of obinutuzumab is required 7 days before initiation.Covered
    MedicationPrior-treatment requirementCoverage
    ElrexfioAt least 4 prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.Covered
    LynozyficAt least 4 prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.Covered
    TalveyAt least 4 prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.Covered
    MedicationPrior-treatment requirementCoverage
    ImdelltraDisease progression on or after platinum-based chemotherapy, such as cisplatin or carboplatin.Covered
    MedicationPrior-treatment requirementCoverage
    Lunsumio or Lunsumio VeloInadequate response or intolerance to 2 or more lines of systemic therapy.Covered
    Medication or regimenPrior-treatment requirementCoverage
    Rybrevant or Rybrevant Faspro for EGFR exon 20 insertion NSCLC — single-agent regimenDisease progression on or after platinum-based chemotherapy, such as cisplatin, carboplatin, or oxaliplatin.Covered
    Rybrevant or Rybrevant Faspro for EGFR exon 20 insertion NSCLC — first-line combination regimenNo prior-treatment requirement stated; first-line treatment is combined with carboplatin and pemetrexed.Covered
    Rybrevant or Rybrevant Faspro for EGFR exon 19 deletion or exon 21 L858R NSCLC — chemotherapy regimenDisease progression on or after treatment with an EGFR tyrosine kinase inhibitor; treatment is combined with carboplatin and pemetrexed.Covered
    Rybrevant or Rybrevant Faspro for EGFR exon 19 deletion or exon 21 L858R NSCLC — Lazcluze regimenNo prior-treatment requirement stated; first-line treatment is combined with Lazcluze (lazertinib).Covered
    Tecvayli pathwayPrior-treatment requirementCoverage
    Combination with daratumumab hyaluronidase-fihjAt least 1 prior line of therapy, including a proteasome inhibitor and an immunomodulatory agent.Covered
    MonotherapyAt least 4 prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.Covered
    MedicationPrior-treatment requirementCoverage
    Ziihera monotherapy for biliary tract cancerPreviously treated unresectable or metastatic HER2-positive biliary tract cancer (IHC 3+ or ISH+).Covered

    Quantity Limits

    Bizengri quantity limit
    DrugBizengri (zenocutuzumab-zbco)
    Quantity limit750 mg per course
    IntervalEvery 2 weeks
    Ziihera quantity limit for biliary tract cancer
    DrugZiihera (zanidatamab-hrii)
    IndicationBiliary tract cancer
    Quantity limit20 mg/kg per course every 2 weeks
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyBispecific Antibody Drug Coverage
    Policy CodePolicy 5.01.650
    Change TypeModified
    Effective DateNov 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateNot specified
    Key ActionSubmit office visit notes documenting the diagnosis, relevant history, physical evaluation, medication history, and applicable medical-necessity criteria.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Dose InformationAuthorization and Documentation RequirementsPolicy BackgroundDefinitionsInitial Therapy CriteriaContinuation and Reauthorization CriteriaPrior Treatment RequirementsQuantity Limits
    Every 2 weeks
    Rybrevant single-agent maintenance dose
    DrugRybrevant (amivantamab-vmjw)
    Treatment settingSingle agent maintenance
    Dose1,400 mg every 2 weeks
    Rybrevant maintenance dose with chemotherapy
    DrugRybrevant (amivantamab-vmjw)
    Treatment settingMaintenance in combination with chemotherapy
    Dose2,100 mg every 3 weeks
    Rybrevant Faspro single-agent maintenance dose
    DrugRybrevant Faspro (amivantamab and hyaluronidase-lpuj)
    Treatment settingSingle-agent maintenance
    Dose options2,240 mg every 2 weeks or 4,640 mg every 4 weeks
    Rybrevant Faspro maintenance dose with chemotherapy
    DrugRybrevant Faspro (amivantamab and hyaluronidase-lpuj)
    Treatment settingMaintenance in combination with chemotherapy
    Dose3,360 mg every 3 weeks
    Rybrevant Faspro maintenance dose with Lazcluze
    DrugRybrevant Faspro (amivantamab and hyaluronidase-lpuj)
    Treatment settingMaintenance in combination with Lazcluze (lazertinib)
    Dose options2,240 mg every 2 weeks or 4,640 mg every 4 weeks
    Ziihera biliary tract cancer dose
    DrugZiihera (zanidatamab-hrii)
    IndicationHER2-positive biliary tract cancer
    Dose20 mg/kg every 2 weeks
    Ziihera dose under 70 kg
    DrugZiihera (zanidatamab-hrii)
    Body weightLess than 70 kg
    Dose options1,200 mg every 2 weeks or 1,800 mg every 3 weeks
    Ziihera dose at least 70 kg
    DrugZiihera (zanidatamab-hrii)
    Body weight70 kg or greater
    Dose1,600 mg every 2 weeks or 2,400 mg; frequency for the 2,400-mg dose is not specified in the policy excerpt
    Documentation Required

    Required Medical Records

    Submit medical records that establish medical necessity for the requested drug and condition.

    • Office visit notes
    • Diagnosis and relevant history
    • Physical evaluation
    • Medication history
    Documentation Required

    Prior Treatment and Specialist Documentation

    Document all drug-specific prior-treatment, response, intolerance, progression, and prescribing requirements before requesting authorization.

    • Document inadequate response, intolerance, or progression after the required prior systemic therapies, including the required number of prior lines when applicable.
    • For multiple myeloma therapies requiring four or more prior lines, document prior treatment with a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.
    • For Tecvayli, document the applicable prior proteasome-inhibitor and immunomodulatory-agent therapy and whether treatment is combined with daratumumab hyaluronidase-fihj or used as monotherapy after four or more prior lines.
    • For Columvi, document pretreatment with a single 1,000 mg intravenous dose of obinutuzumab 7 days before initiation.
    • Document progression on or after platinum-based chemotherapy when required for Imdelltra and the required treatment regimen or disease progression for Rybrevant or Rybrevant Faspro.
    • Ensure the drug is prescribed by or used in consultation with an oncologist when required, including for Imdelltra and Ziihera.
    Denial Risk

    Unlisted or Noncriteria Use

    Uses outside the policy's listed coverage criteria are considered investigational and are not covered under these criteria.

    • Other uses of Rybrevant (amivantamab-vmjw) for solid tumors or hematologic malignancies not listed in the policy are investigational.
    • All other uses of the medications listed in the policy are investigational.
    • The medications remain subject to the product's U.S. Food and Drug Administration dosage and administration prescribing information.
    Denial Risk

    Insufficient Response Documentation

    For reauthorization, submit chart notes demonstrating that the individual continues to meet the applicable drug-specific coverage criteria and is showing a positive clinical response to therapy.

    • Document ongoing response, disease control, or other clinically positive benefit.
    • Failure to document continued criteria satisfaction and positive response may result in denial of reauthorization.
    Documentation Required

    Complete Clinical Documentation

    The submitted record must establish that the applicable medical-necessity criteria are met for the requested drug, diagnosis, treatment setting, and regimen.

    • Include complete, current office visit notes with the diagnosis, relevant history, physical evaluation, and medication history.
    • Include required biomarker, disease-stage, prior-treatment, dosing, combination-therapy, and specialist documentation when applicable.
    • Incomplete or insufficient records may prevent confirmation of medical necessity and result in denial or a request for additional information.
    BCMA-directed bispecific antibody
    Target 1BCMA on plasma cells, plasmablasts, and multiple myeloma cells
    Target 2CD3 on T-cells
    ResultPromotes proinflammatory cytokine release and cytolysis of BCMA-expressing cells
    T-cell-engaging bispecific antibody
    Target 1CD3 on T-cells
    Target 2CD20 on lymphoma cells and some healthy B-lineage cells
    ResultActivates T-cells and induces B-cell lysis
    Lynozyfic mechanism
    DrugLynozyfic (linvoseltamab-gcpt)
    TargetsCD3 on T-cells and BCMA on multiple myeloma cells and some healthy B-lineage cells
    ResultCytokine release and lysis of multiple myeloma cells
    EGFR/MET bispecific antibody
    Target 1Extracellular domain of EGFR
    Target 2Extracellular domain of MET
    ResultDisrupts signaling and promotes immune-effector-cell destruction of tumor cells
    HER2-positive BTC
    Cancer typeBiliary tract cancer (BTC)
    AssessmentCentrally assessed HER2 status
    HER2-positive definitionIHC 2+ or 3+
    HER2-positive GEA
    Cancer typeGastroesophageal adenocarcinoma (GEA)
    AssessmentCentral HER2 testing
    HER2-positive definitionIHC 3+ or IHC 2+/ISH+

    Columvi

    Columvi may be considered medically necessary when all criteria are met.

    Columvi: Age at least 18 years; relapsed or refractory DLBCL, NOS, or LBCL arising from follicular lymphoma; inadequate response to at least 2 systemic-therapy lines; and pretreatment with one 1,000 mg IV dose of obinutuzumab 7 days before initiation.At least 2 prior lines; obinutuzumab 1,000 mg IV 7 days before initiation

    Elrexfio

    Elrexfio may be considered medically necessary when all criteria are met.

    Elrexfio: Age at least 18 years; relapsed or refractory multiple myeloma; and at least 4 prior therapy lines including a proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody.At least 4 prior lines

    Epkinly for DLBCL

    Epkinly may be considered medically necessary when all criteria are met.

    Epkinly DLBCL: Age at least 18 years; relapsed or refractory DLBCL, NOS, including DLBCL arising from indolent lymphoma, or high-grade B-cell lymphoma; and at least 2 prior systemic-therapy lines.At least 2 prior lines

    Epkinly for follicular lymphoma

    Epkinly may be considered medically necessary when all criteria are met.

    Epkinly follicular lymphoma: Age at least 18 years; relapsed and refractory follicular lymphoma; and either combination with lenalidomide and rituximab or monotherapy after at least 2 systemic-therapy lines.At least 2 prior lines for monotherapy

    Imdelltra

    Imdelltra may be considered medically necessary when all criteria are met.

    Imdelltra: Age at least 18 years; relapsed or refractory extensive-stage small cell lung cancer; progression on or after platinum-based chemotherapy; and prescribed by or in consultation with an oncologist.Progression after platinum-based chemotherapy

    Lynozyfic

    Lynozyfic may be considered medically necessary when all criteria are met.

    Lynozyfic: Age at least 18 years; relapsed or refractory multiple myeloma; and at least 4 prior therapy lines including a proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody.At least 4 prior lines

    Lunsumio and Lunsumio Velo

    Lunsumio or Lunsumio Velo may be considered medically necessary when all criteria are met.

    Lunsumio: Age at least 18 years; relapsed or refractory follicular lymphoma; and inadequate response or intolerance to at least 2 systemic-therapy lines.At least 2 prior lines

    Applies to IV Lunsumio and SC Lunsumio Velo.

    Rybrevant and Rybrevant Faspro

    Rybrevant and Rybrevant Faspro may be considered medically necessary when all criteria are met.

    Rybrevant formulations: Age at least 18 years and locally advanced or metastatic NSCLC with the applicable EGFR mutation. For exon 20 insertion mutations, use is after platinum-based chemotherapy as a single agent or first-line with carboplatin and pemetrexed. For exon 19 deletions or exon 21 L858R mutations, use is after an EGFR tyrosine kinase inhibitor with carboplatin and pemetrexed or first-line with Lazcluze. Maintenance dose limits vary by formulation and combination.See formulation- and combination-specific maintenance limits

    Talvey

    Talvey may be considered medically necessary when all criteria are met.

    Talvey: Age at least 18 years; relapsed or refractory multiple myeloma; and at least 4 prior therapy lines including a proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody.At least 4 prior lines

    Tecvayli

    Tecvayli may be considered medically necessary when all criteria are met.

    Tecvayli: Age at least 18 years and relapsed or refractory multiple myeloma, with either at least 1 prior line including a proteasome inhibitor and immunomodulatory agent plus combination daratumumab hyaluronidase-fihj, or at least 4 prior lines including a proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody plus Tecvayli monotherapy.At least 1 or at least 4 prior lines depending on pathway

    Ziihera

    Ziihera may be considered medically necessary when all criteria are met.

    Ziihera biliary tract cancer: Age at least 18 years; unresectable or metastatic HER2-positive biliary tract cancer with IHC 3+ or ISH+; previously treated; monotherapy; prescribed by or in consultation with an oncologist; and dose limited to 20 mg/kg every 2 weeks.20 mg/kg every 2 weeks
    Ziihera gastric or esophageal adenocarcinoma: Age at least 18 years; unresectable locally advanced or metastatic gastric, gastroesophageal junction, or esophageal adenocarcinoma; HER2-positive; first-line use; prescribed by or in consultation with an oncologist; required chemotherapy and tislelizumab combination determined by HER2 result; and weight-based dose limits apply.Under 70 kg: 1,200 mg every 2 weeks or 1,800 mg every 3 weeks; 70 kg or greater: 1,600 mg every 2 weeks or 2,400 mg