CommercialPrior AuthHigh impact
Evinacumab-dgnb (Evkeeza) (CPB 0989, reviewed 2026-04-10)
Aetna·Cardiology, Endocrinology, Genetics +1 more·Medical Policy
Effective date
Apr 10, 2026
We identified it
Aug 13, 2026
Summary
Aetna has released a new clinical policy for evinacumab-dgnb (Evkeeza) effective immediately for treating homozygous familial hypercholesterolemia (HoFH) in members age 1 and older. The policy requires precertification for all claims, specialist prescribing (cardiologist, endocrinologist, lipid specialist, geneticist), and strict clinical criteria including genetic confirmation of HoFH and prior optimization with lipid-lowering therapies based on age group.
Action Required
IMMEDIATE ACTION REQUIRED: (1) Billing team must set up precertification requirement in claims system for evinacumab-dgnb (Evkeeza) for all Aetna commercial plans. (2) Create prior authorization workflow: all Evkeeza claims must route to precertification department before processing. Call (866) 752-7021 or fax (888) 267-3277 for precertification requests using Statement of Medical Necessity (SMN) forms from Specialty Pharmacy Precertification. (3) Update provider alerts and encounter forms to flag that only cardiologists, endocrinologists, lipid specialists, geneticists, or HoFH-specialized prescribers can order this drug. (4) Verify member meets clinical criteria before submitting: documented HoFH diagnosis (genetic confirmation), LDL-C levels at specified thresholds, prior treatment with appropriate lipid-lowering therapies at max tolerated dose based on age (requirements vary for ages 1-7, 7-10, and 10+), and continuation therapy requires LDL-C at goal OR 30% reduction from baseline. (5) Claims submitted without precertification will be denied. (6) Site of Care Utilization Management Policy also applies—verify infusion setting is appropriate before claims processing.