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OfficeLink Updates - July 2026 notices and reminders (PDF)
Effective date
Jul 1, 2026
Identified
Jun 25, 2026
Summary
Aetna's National Precertification List changes take effect in stages: on July 1, 2026, precertification was removed for Tegsedi and the iui case rate and added for several biosimilars, specialty drugs and hypoglossal nerve neurostimulator procedures, with further changes on August 1, 2026 and October 1, 2026. Effective October 1, 2026, Florida Dual-Eligible Special Needs Plans require precertification for certain home health aide, certified nurse assistant and personal care services. Beginning in 2027, maternity care will be reported as separate services for each phase of care instead of a single global service, and the transition period for remote physiological monitoring members runs through December 31, 2026.
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What to do
Action · 18 steps
01Already effective July 1, 2026: Request precertification at least two weeks in advance and include the actual date of service.
02Billing team: submit through the Availity provider portal, through your EMR system if it is set up for electronic precertification requests, or through Novologix for specialty drugs for commercial or Medicare members.
03Use the 'Search by CPT code' function on the Precertification Lists page to check whether a code requires precertification.
04Precertification is now required for Yartemlea (J1289), Fesilty (J7176), Blenrep (J9053), Otarmeni (J3490, J3590, C9399), the biosimilars Starjemza (Q5164), Oziltus (Q5165), Osvyrti/Jubereq (Q5166), Enoby/Xtrenbo (Q5167), Nufymco (Q5168), Armlupeg (Q5169), Eydenzelt (Q5170) and Boncresa (Q5171), and the hypoglossal nerve neurostimulator procedures C8007, C8008, C8009, C8011, C8012 and C8013.
05Precertification and Site of Care review are now required for Saphnelo SC (J3490, J3590, C9399), Qivigy (J1577), Exdensur (J2361), Waskyra (J3386), Itvisma (J3405) and Rybrevant Faspro (J9062).
06Precertification was removed for Tegsedi (J3490, J3590, C9399) and iui case rate (S4035) was removed from the National Precertification List.
07Already effective August 1, 2026: Precertification is required for Evdi (J3490, J3590, J9999, C9399), Ennumo (J3490, J3590, C9399) and Decnupaz (J3490, J3590, C9399, J9999).
08Precertification and Site of Care review are required for Immgolis/Immgolis Intri (J3490, J3590, C9399).
09Precertification is no longer required for Zulresso (J1632), and precertification and Site of Care review are no longer required for Beqvez (C9172, J1414).
10For commercial members, GamaSTAN S/D (J1460, J1559, J1560) no longer requires Site of Care review, but precertification remains.
11Already effective October 1, 2026: Precertification is required for Gamifant (J9210) and Lutathera (A9513).
12Commercial members need an additional Site of Care review for Darzalex Faspro (J9144), Evenity (J3111), Xgeva (J0897) and the denosumab products Aukelso (Q5161), Bilprevda (Q5162), Bomyntra (Q5158), Jubereq (Q5166), Osenvelt (Q5157), Wyost (Q5136), Xbryk (Q5159) and Xtrenbo (Q5167).
13For Florida Dual-Eligible Special Needs Plans, precertification is required for home health aide or certified nurse assistant care in the home per hour (S9122), personal care services per hour (T1019), personal care services per diem (T1020) and home health aide or certified nurse assistant per visit (T1021).
14Future change beginning 2027: Maternity care will no longer be reimbursed as a single global service.
15Report services separately across antepartum (prenatal) care, labor management, delivery and postpartum care.
16Continue following current billing practices until further guidance is issued, and watch the provider portal on Availity for the FAQ and the billing and reimbursement details Aetna will share.
17Remote physiological monitoring (CPT 99453 through 99458): members currently using RPM have a transition period through December 31, 2026.
18Effective January 1, 2027, all members must meet policy requirements to continue services, and members meeting clinical criteria for heart failure, hypertension or diabetes continue to qualify under CPB 1093.
Codes mentioned
S4035J3490J3590C9399J9999J1289J7176J9053Q5164Q5165Q5166Q5167Q5168Q5169Q5170Q5171J1577J2361J3386J3405J9062C8007C8008C8009C8011C8012C8013J1632C9172J1414J1460J1559J1560J9210A9513J9144J3111J0897Q5161Q5162Q5158Q5157Q5136Q5159S9122T1019T1020T10219945399458
Original notice
OfficeLink Updates - July 2026 notices and reminders (PDF)
aetna.com · Always check the source before changing claims.
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Related policy hubs
Aetna policiesOncologyHematologyRheumatologyNeurologyOB-GYNOphthalmologySleep MedicineCode S4035Code J3490Code J3590Code C9399Code J9999Code J1289Code J7176Code J9053Code Q5164Code Q5165Code Q5166Code Q5167Code Q5168Code Q5169Code Q5170Code Q5171Code J1577Code J2361Code J3386Code J3405Code J9062Code C8007Code C8008Code C8009Code C8011Code C8012Code C8013Code J1632Code C9172Code J1414Code J1460Code J1559Code J1560Code J9210Code A9513Code J9144Code J3111Code J0897Code Q5161Code Q5162Code Q5158Code Q5157Code Q5136Code Q5159Code S9122Code T1019Code T1020Code T1021Code 99453Code 99458