CommercialPrior AuthMedium impact
Plasminogen, Human-tvmh (Ryplazim) (CPB 0976, reviewed 2026-02-17)
Aetna·Hematology, Pediatrics, Ophthalmology·Medical Policy
Effective date
Feb 17, 2026
We identified it
Aug 13, 2026
Summary
Aetna has established coverage criteria for Ryplazim (plasminogen, human-tvmh) for treatment of plasminogen deficiency type 1. The policy requires precertification for all claims, prescriber consultation with a hematologist, baseline plasminogen activity ≤45%, and documented clinical symptoms. All other indications are considered experimental/investigational.
Action Required
Effective immediately: (1) Billing team must implement precertification requirement for all Ryplazim claims (J2998) before submission. Contact Aetna at (866) 752-7021 or fax (888) 267-3277 for precertification using Statement of Medical Necessity (SMN) form available at Specialty Pharmacy Precertification portal. (2) Update billing software to flag J2998 claims requiring prior authorization and verify hematologist involvement before processing. (3) Providers must document baseline plasminogen activity level ≤45% and clinical manifestations (ligneous conjunctivitis, ligneous gingivitis, vision abnormalities, respiratory distress/obstruction, or abnormal wound healing) on all claims. (4) Continuation of therapy requires documentation of disease stability or improvement. (5) Claims submitted without precertification or missing required clinical documentation will be denied. Train billing staff and providers on these requirements immediately.