CommercialPrior AuthHigh impact
Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)
Aetna·Oncology, Hematology, Palliative Care·Medical Policy
Effective date
Jan 27, 2026
We identified it
Aug 13, 2026
Summary
Aetna has updated its coverage policy for Dostarlimab-gxly (Jemperli), an immunotherapy drug, effective immediately (reviewed 2026-01-27). The policy establishes specific medical necessity criteria for coverage across multiple cancer types including endometrial, colorectal, ovarian, pancreatic, and non-small cell lung cancers, with mandatory precertification required before treatment initiation. Billing teams must implement prior authorization workflows and ensure claims include documentation of MSI-H/dMMR status or other required biomarkers.
Action Required
Effective immediately (2026-01-27): Billing team must implement mandatory precertification process for all Dostarlimab-gxly (Jemperli) claims on Aetna commercial plans. (1) Update billing system to flag all CPT codes 96413-96417 (chemotherapy administration) when linked to Jemperli for automatic prior authorization routing. (2) Train front-desk and authorization staff to contact Aetna precertification at (866) 752-7021 or fax (888) 267-3277 BEFORE treatment initiation. (3) Ensure providers document medical necessity including: cancer type, disease stage (recurrent/advanced/metastatic), prior treatment history, biomarker status (MSI-H or dMMR), and confirmation of no satisfactory alternative treatments. (4) Create encounter form checklist for oncologists specifying required documentation elements. (5) Update billing templates to capture biomarker test results (MSI-H, dMMR, POLE/POLD1, TMB) and line of therapy information. (6) Cross-reference approved indications per policy (endometrial, colorectal, breast, pancreatic, ovarian, esophageal, gastric, lung, etc.) to deny claims for non-covered indications or those marked 'experimental/investigational.' (7) Flag any claims for members with prior PD-1/PD-L1 inhibitor disease progression for denial per exclusion criteria. Claims submitted without precertification or missing required documentation will be denied.