CommercialPrior AuthHigh impact
Elranatamab-bcmm (Elrexfio) (CPB 1040, reviewed 2025-12-10)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Dec 10, 2025
We identified it
Aug 13, 2026
Summary
Aetna has established a new coverage policy for elranatamab-bcmm (Elrexfio), a bispecific T-cell engager for relapsed or refractory multiple myeloma. The policy requires precertification for all commercial plans and limits coverage to patients who have received at least 4 prior therapies including specific drug classes (anti-CD38 monoclonal antibody, proteasome inhibitor, and immunomodulatory agent). Billing teams must implement prior authorization requirements and update systems to reflect the specific dosing schedules and eligibility criteria.
Action Required
IMMEDIATELY (effective 2025-12-10): Billing team must implement precertification requirement for elranatamab-bcmm (Elrexfio) injections. (1) Update billing system to flag all claims with HCPCS code J1323 as requiring precertification before processing. (2) Configure prior authorization workflow to route J1323 claims to precertification team with contact numbers: (866) 752-7021 or fax (888) 267-3277. (3) Update encounter forms and provider documentation templates to require verification of at least 4 prior therapies including: one anti-CD38 monoclonal antibody (daratumumab, isatuximab), one proteasome inhibitor (bortezomib, ixazomib, carfilzomib), and one immunomodulatory agent (lenalidomide, pomalidomide, thalidomide) before claim submission. (4) Train billing and precertification staff on eligibility criteria and dosing schedules (step-up: 12 mg Day 1, 32 mg Day 4, 76 mg Day 8, then weekly x24 weeks, then biweekly for responders). (5) Educate providers that ICD-10 codes C90.00 and C90.02 (multiple myeloma) with J1323 will automatically trigger precertification requirements. CONSEQUENCES: Claims submitted without prior authorization will be denied. Lack of proper documentation of prior therapy eligibility will result in coverage denial.