CommercialPrior AuthMedium impact
Caplacizumab-yhdp (Cablivi) (CPB 0949, reviewed 2025-12-03)
Aetna·Hematology, Critical Care, Internal Medicine·Medical Policy
Effective date
Dec 3, 2025
We identified it
Aug 12, 2026
Summary
Aetna updated its Clinical Policy Bulletin for Caplacizumab-yhdp (Cablivi) effective December 3, 2025, establishing coverage criteria for acquired thrombotic thrombocytopenic purpura (aTTP) treatment. All claims require precertification before submission. Coverage is limited to 30 days post-plasma exchange, with a maximum 28-day extension only if persistent aTTP is documented, and therapy must be discontinued if more than 2 recurrences occur.
Action Required
By December 3, 2025: (1) Billing team must implement mandatory precertification requirement for all Caplacizumab-yhdp (Cablivi) claims - set up system rules to block claims without prior authorization approval. Contact Aetna at (866) 752-7021 or fax (888) 267-3277 to establish precertification process. (2) Providers must document and submit with precertification requests: (a) confirmation of plasma exchange administration, (b) concurrent immunosuppressive therapy plan, (c) ADAMTS13 activity level, and (d) evidence of no more than 2 prior aTTP recurrences requiring plasma exchange reinitiation. (3) Billing software must enforce 30-day treatment limit from last plasma exchange date and flag any requests beyond 30 days unless persistent aTTP criteria are met (ADAMTS13 <10% OR all three of: schistocytes on smear, thrombocytopenia, elevated LDH). (4) System must prevent approval of extension therapy beyond initial 28-day extension per treatment course and deny claims if patient exceeds 2 recurrences. (5) Update encounter forms and billing templates to capture treatment dates relative to plasma exchange cessation. Failure to obtain precertification will result in claim denials. All other indications remain experimental/non-covered.