CurrentAetnaPolicy N/A

Empliciti (elotuzumab) Precertification Request — Coverage Criteria

Precertification form and requirements for Aetna coverage review of Empliciti (elotuzumab) for patients with multiple myeloma; used by providers to request initiation or continuation of therapy.

Policy Summary

PayerAetna

PolicyEmpliciti (elotuzumab) Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the Empliciti precertification form to Aetna (phone/fax listed) prior to or at the start or continuation of therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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3regimen options

2admin settings

Coverage Criteria for Empliciti (elotuzumab)

General coverage considerations for Empliciti precertification

Coverage assessment uses documented diagnosis of multiple myeloma, selected combination regimen, and prior therapy history.

Root

Diagnosis: Patient has a diagnosis of multiple myeloma (Yes/No)
Chunk 8
Regimen selection: Selected Empliciti regimen: in combination with lenalidomide + dexamethasone OR bortezomib + dexamethasone OR pomalidomide + dexamethasone
Chunk 8
Prior therapy for certain regimens: For initiation requests document prior therapy status: for lenalidomide or bortezomib combinations indicate if patient received at least one prior regimen; for pomalidomide combination indicate if patient received at least two prior regimens including a proteasome inhibitor (PI) and an immunomodulatory agent (IMiD)

Policy Summary

PayerAetna

PolicyEmpliciti (elotuzumab) Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the Empliciti precertification form to Aetna (phone/fax listed) prior to or at the start or continuation of therapy.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered regimen
Empliciti (elotuzumab) in combination with lenalidomide + dexamethasone
Empliciti (elotuzumab) in combination with bortezomib + dexamethasone
Empliciti (elotuzumab) in combination with pomalidomide + dexamethasone (requires at least two prior regimens including a proteasome inhibitor and an immunomodulatory agent)

Required Provider Actions and Submission Instructions

Documentation Required

Administrative documentation required

Complete and legible administrative information is required on the precertification form. Provide full patient demographics (name, DOB, address, contact numbers, height/weight, allergies), insurance details (Aetna Member ID, group #, other coverage and IDs, Medicare/Medicaid status), prescriber information (name, credentials, address, phone, fax, NPI, license, specialty), dispensing/provider and administration details (place of administration, provider/pharmacy name, address, phone, TIN/PIN, administration CPT codes), and product information (Empliciti dose and frequency).

Patient demographics: name, DOB, address, phones, email, height/weight, allergies
Insurance: Aetna member ID, group #, other coverage and corresponding ID(s), Medicare/Medicaid indicators
Prescriber: name, credentials, address, phone, fax, NPI, state license, specialty
Dispensing/Administration: place of administration, facility/agency name, phone, pharmacy/provider name, address, TIN/PIN, selected dispensing choice, administration CPT codes
Product: Empliciti (elotuzumab) dose and frequency

Documentation Required

Prior therapy documentation (clinical)

Document prior therapies and the current prescribed Empliciti regimen for all initiation requests. Indicate whether multiple myeloma was previously treated and list prior regimens. For initiation regimens, check the specific combination being prescribed (with lenalidomide + dexamethasone; bortezomib + dexamethasone; pomalidomide + dexamethasone; or other). For patients receiving Empliciti after prior therapy, document whether the patient has received at least two prior regimens including a proteasome inhibitor and an immunomodulatory agent, or explain other circumstances.

Confirm diagnosis of multiple myeloma
State whether disease was previously treated and list all prior regimens
If selecting lenalidomide, bortezomib, or pomalidomide combinations, indicate if patient received at least one prior regimen for that combination where queried
For later-line use: document ≥2 prior regimens including a proteasome inhibitor (e.g., bortezomib) and an immunomodulatory agent (e.g., lenalidomide) or explain deviations

Denial Risk

Fraud / incomplete information risk

Submitting false or intentionally incomplete information may constitute insurance fraud and can result in denial of the request and civil or criminal penalties. The plan may request additional information or clarification to evaluate requests. Ensure the signature/date section is completed by the requestor.

Fraud warning: knowingly providing materially false or concealed information is a fraudulent insurance act
Plan may request additional information or clarification as needed
Signed attestation: Request Completed By (signature) and Date must be provided

Request Types

Initiation request — required documentation

DefinitionInitiation request: Request to start Empliciti (elotuzumab) therapy; requires documentation whether the patient has a diagnosis of multiple myeloma and whether the disease has been previously treated, and selection of the prescribed combination regimen (lenalidomide + dexamethasone, bortezomib + dexamethasone, or pomalidomide + dexamethasone).

Prior therapy requirementFor initiation with lenalidomide or bortezomib combinations: indicate if the patient has received at least one prior regimen (Yes/No).

Pomalidomide combination specificFor initiation with pomalidomide + dexamethasone: document receipt of at least two prior regimens including a proteasome inhibitor (PI) and an immunomodulatory agent (IMiD) (Yes/No/Other—explain).

Regimen selectionSpecify which Empliciti combination is prescribed: lenalidomide + dexamethasone; bortezomib + dexamethasone; or pomalidomide + dexamethasone.

Continuation request — required documentation

DefinitionContinuation request: Request to continue ongoing Empliciti (elotuzumab) therapy; requires documentation of current treatment status and outcomes while on the regimen.

Last treatment documentationProvide date of last Empliciti treatment (document on form).

Toxicity/progressionDocument whether the patient experienced unacceptable toxicity or disease progression while on the current regimen (Yes/No).

Ongoing regimen confirmationConfirm the combination regimen being continued (lenalidomide + dexamethasone; bortezomib + dexamethasone; or pomalidomide + dexamethasone).

Background

Empliciti (elotuzumab) is intended for use in combination regimens for the treatment of multiple myeloma. The precertification form collects the information necessary to assess appropriateness, including whether the request is for initiation or continuation, confirmation of diagnosis, the selected combination regimen (lenalidomide + dexamethasone; bortezomib + dexamethasone; or pomalidomide + dexamethasone), and prior therapy history (including whether the patient has received at least one prior regimen or, for the pomalidomide combination, at least two prior regimens including a proteasome inhibitor and an immunomodulatory agent). For continuation requests the form also requires documentation of whether the patient has experienced unacceptable toxicity or disease progression on the current regimen.

Administration code(s) (CPT)	Administration CPT codes — to be specified by provider on form
Primary ICD Code	Primary diagnosis ICD code — to be specified by provider on form
Secondary ICD Code	Secondary diagnosis ICD code — to be specified by provider on form
Other ICD Code	Other diagnosis ICD code — to be specified by provider on form

OpenPayer

Empliciti (elotuzumab) Precertification Request — Coverage Criteria

Coverage Criteria for Empliciti (elotuzumab)

Billing and Diagnosis Codes

Required Provider Actions and Submission Instructions

Request Types

Line of Therapy Classification

Background