CurrentAetnaPolicy N/A

Elrexfio (elranatamab-bcmm) precertification request form — coverage criteria

Precertification/authorization form and requirements for Elrexfio (elranatamab-bcmm) for Aetna members, capturing patient, prescriber, dispensing, diagnosis, and clinical criteria for initiation and continuation of therapy.

Policy Summary

PayerAetna

PolicyElrexfio (elranatamab-bcmm) precertification request form — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed precertification form documenting diagnosis, prior therapies (≥4), product dose/frequency, and required clinical information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page(s) in document

>=4prior therapies required

3therapy categories listed

1-866-752-7021Aetna Precert phone

Coverage Criteria

Initiation Therapy

Policy Summary

PayerAetna

PolicyElrexfio (elranatamab-bcmm) precertification request form — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed precertification form documenting diagnosis, prior therapies (≥4), product dose/frequency, and required clinical information.

SourceLink

On This Page

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Initiation criteria: Patient has diagnosis of multiple myeloma; documentation indicates relapsed or refractory disease (or other specified setting); patient has received at least four prior therapies for multiple myeloma including an anti-CD38 monoclonal antibody and a proteasome inhibitor (form also asks about an immunomodulatory agent).at least four prior therapies

Form lists example agents: daratumumab; bortezomib, ixazomib, carfilzomib; lenalidomide, pomalidomide

Initial Therapy

Initial therapy

Initiation requests must provide diagnosis, treatment setting, prior therapies, and product dose/frequency.

Initial therapy: Diagnosis: Multiple myeloma; Indicate treatment setting (Relapsed, Refractory, or Other); Document whether the patient has received at least four prior therapies including at least one anti-CD38 monoclonal antibody and at least one proteasome inhibitor (form also queries an immunomodulatory agent).at least four prior therapies

Product requested and dosing/frequency must be provided on the product information section of the form.

Continuation Therapy

Continuation therapy

Continuation requests must document ongoing clinical status.

Continuation: Provide date of last treatment and indicate whether there is evidence of unacceptable toxicity or disease progression while on the current regimen (Yes/No).

Form requires completion of clinical information for all continuation requests.

Billing & Diagnosis Codes

Requested billing codes and diagnosis codesmixed

Administration code(s) (CPT)	Administration CPT codes — form requests applicable administration CPT codes
Primary ICD Code / Secondary ICD Code / Other ICD Code	Placeholders for ICD-10 diagnosis codes related to multiple myeloma

Prior therapy count

Required prior therapiesPatient must have received at least four prior therapies for multiple myeloma

Required drug classes (examples provided)Includes at least one anti-CD38 monoclonal antibody (e.g., daratumumab)

Required drug classes (examples provided)Includes at least one proteasome inhibitor (e.g., bortezomib, ixazomib, carfilzomib)

Optional/asked classForm asks about an immunomodulatory agent (e.g., lenalidomide, pomalidomide)

Provider Actions & Requirements

Prior Authorization

Precertification Required

Precertification is required for Elrexfio (elranatamab‑bcmm). The precertification form must indicate whether this is a start or continuation of therapy, include the product name, dose and frequency, and relevant clinical details to support the request.

Use Aetna Precertification Notification form; for Medicare Advantage Part B use the Medicare Request Form.
Form must indicate: Start of treatment (with start date) or Continuation of therapy (with date of last treatment).
Include prescriber and requestor contact information (phone, fax).

Documentation Required

Required Documentation

Completed precertification form and supporting clinical documentation are required for all requests. The form must be legible and fully completed and must include patient, insurance, prescriber, dispensing, product, ICD diagnosis, and the required clinical information.

Attach documentation of diagnosis (Multiple Myeloma) and clinical setting (relapsed, refractory, or other).
For continuation requests, include documentation regarding response and any unacceptable toxicity or disease progression on current regimen.
Fax or call per Aetna contact info: Fax 1-888-267-3277; Phone 1-866-752-7021 (TTY:711).

Step Therapy

Prior Therapy / Step Requirement

The precertification form asks whether the patient has received at least four prior therapies for multiple myeloma, and specifically documents receipt of therapies from key drug classes.

Form includes checkbox: Has the patient received at least four prior therapies for multiple myeloma? Yes / No.
Form specifically asks to indicate receipt of: A) anti‑CD38 monoclonal antibody (e.g., daratumumab); B) proteasome inhibitor (e.g., bortezomib, ixazomib, carfilzomib); C) immunomodulatory agent (e.g., lenalidomide, pomalidomide).

Denial Risk

Prior Therapy Documentation — Denial Risk

Failure to document that the patient received at least four prior therapies for multiple myeloma — including at least one anti‑CD38 monoclonal antibody, one proteasome inhibitor, and one immunomodulatory agent — may result in denial of the precertification request.

Ensure checkboxes and supporting records clearly show prior treatment history and dates.
If requesting continuation, include evidence of clinical benefit or reasons for ongoing therapy.

Step	Requirement
1	Documentation that the patient has received at least four prior therapies for multiple myeloma, with confirmation that prior treatment includes an anti-CD38 monoclonal antibody (e.g., daratumumab) and a proteasome inhibitor (e.g., bortezomib, ixazomib, carfilzomib).

Site of Care

Note

Specify place of administration (site of care)

Indicate the place of administration on the form — options include self‑administered, physician's office, outpatient infusion center, or home infusion center.

Select one of: Self‑administered; Physician's Office; Outpatient Infusion Center; Home Infusion Center.
Provide associated phone/center name or agency name as requested in the dispensing/administration section.

Definitions / Request Types

Initiation Requests — clinical documentation required for starting Elrexfio

Initiation documentation requiredCompleted clinical information section documenting diagnosis (Multiple Myeloma) and treatment setting (Relapsed, Refractory, or Other)

Prior therapy documentationAnswer whether the patient has received at least four prior therapies and indicate exposure to the listed drug classes

Drug class detailsIndicate specific prior agents where applicable (anti-CD38 e.g., daratumumab; proteasome inhibitors e.g., bortezomib, ixazomib, carfilzomib; immunomodulatory agents e.g., lenalidomide, pomalidomide)

Continuation prompt on same formFor continuation requests, document date of last treatment and answer whether there is evidence of unacceptable toxicity or disease progression while on current regimen (Yes/No)

Continuation Requests — required clinical documentation

Continuation documentation requiredProvide documentation and indicate whether there is evidence of unacceptable toxicity or disease progression while on the current regimen (Yes/No)

Clinical statusDocument ongoing clinical status to justify continuation

Form response formatContinuation question appears as a Yes/No item on the precertification form

Background

Elrexfio (elranatamab-bcmm) is requested for treatment of multiple myeloma in relapsed or refractory settings. The precertification form captures prior lines of therapy, asks whether the disease is relapsed or refractory, and requests documentation of prior therapies (including whether the patient has received at least four prior therapies and exposure to drug classes such as anti‑CD38 monoclonal antibody, proteasome inhibitor, and immunomodulatory agents). For continuation requests the form asks for the date of last treatment and documentation of unacceptable toxicity or disease progression on the current regimen.

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