Tecvayli will have additional requirements for most commercial members, starting Dec. 7

Blue Cross Blue Shield of Michigan and Blue Care Network are updating the medical policy for Tecvayli^® (teclistamab-cqyv), HCPCS code J9380. The requirements in the updated medical policy will apply for most Blue Cross and BCN commercial members for dates of service on or after Dec. 7, 2023.

In keeping with the updated medical policy, members will have to meet the following additional requirements for treatment with Tecvayli to be considered medically necessary:

• Alanine aminotransferase, or ALT, and aspartate aminotransferase, or AST, less than or equal to three times the upper limit of normal, or ULN
• Creatinine clearance greater than or equal to 40 mL/min
• Left ventricular ejection fraction greater than or equal to 40%
• No active autoimmune disease except vitiligo, Type 1 diabetes mellitus or prior autoimmune thyroiditis

You can see the full list of requirements in the updated medical policy, which will be available by Dec. 7. To view the policy, go to the Medical Policy Router Search page, enter the name of the drug in the Policy/Topic Keyword field and press Enter. The search results will include links to both the current medical policy and the updated medical policy.

Note: To access the Medical Policy Router Search page, go to bcbsm.com/providers, click on Resources and then click on Search Medical Policies.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don’t participate in the standard prior authorization program.

Additional information

For additional information about drugs covered under the medical benefit, see the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.