Cabotegravir and Rilpivirine (Cabenuva) (CPB 0987, reviewed 2026-04-02)

Immediately: Billing team must implement mandatory precertification process for all Cabenuva (J0741) claims submitted to Aetna commercial plans. Update billing system to flag J0741 claims as requiring prior authorization before submission. Establish internal workflow to obtain Statement of Medical Necessity (SMN) from prescribers before claims are processed. Contact precertification at (866) 752-7021 or fax (888) 267-3277 for all member requests. Before April 2, 2026: Train billing and prior authorization staff on two approval pathways—virologically suppressed patients (HIV RNA <50 copies/mL, no treatment failure, no resistance) versus treatment-experienced patients with viremia (CD4 <200 or AIDS history, failed oral ART despite adherence support). Ensure providers document viral load results, CD4 counts, treatment history, and resistance testing status on precertification requests. Update encounter forms and EMR templates to capture required clinical data. Set up system rules requiring site-of-care documentation per Aetna's Utilization Management Policy for specialty drug infusions. Failure to obtain precertification will result in claim denials. Ensure providers understand that Cabenuva is a complete regimen and cannot be billed with other antiretroviral medications (CPT 96372 applies to administration only; do not duplicate with other ART billing).