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AetnaCommercial · Coverage · Medical Policy · Oncology, OB-GYN, Urology +1 moreMedium impact

Pemetrexed Products (CPB 0687, reviewed 2026-07-17)

Effective date
Not stated in the notice
Identified
Aug 13, 2026

Summary

Aetna considers pemetrexed (Alimta, Axtle, Pemfexy, Pemrydi RTU, or generic pemetrexed) medically necessary for commercial members with the listed indications: non-squamous non-small cell lung cancer, pleural and peritoneal mesothelioma, ovarian, fallopian tube and primary peritoneal cancer, cervical cancer, bladder cancer, primary CNS lymphoma, thymoma and thymic carcinoma, thyroid cancer, and vaginal cancer. Members with squamous cell non-small cell lung cancer are not eligible, and indications such as breast, colorectal, gastric, pancreatic and small cell lung cancer are experimental, investigational, or unproven. Continuation is covered when there is no unacceptable toxicity or disease progression, and use with pembrolizumab for pleural or peritoneal mesothelioma is covered for up to 24 months total.

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What to do

Action · 8 steps
01Billing team: Confirm the claim diagnosis is one of the covered ICD-10 codes in the policy, such as C45.0 for pleural mesothelioma, C67.0 to C67.9 for bladder cancer, C53.0 to C53.9 for cervical cancer, and C56.1 to C57.02 for ovarian or fallopian tube cancer.
02Non-squamous non-small cell lung cancer is covered under C33 to C34.92.
03Diagnoses C50.011 to C50.A2 (breast), C18.0 to C20 (colorectal), C16.0 to C16.9 (gastric) and C25.0 to C25.9 (pancreatic) are listed as not covered for pemetrexed, so do not bill pemetrexed under those codes.
04Members with squamous cell non-small cell lung cancer are not eligible for pemetrexed.
05Billing team: Match the pemetrexed HCPCS code to the product given, for example J9305 for pemetrexed 10 mg, J9304 for Pemfexy 10 mg, or J9324 for Pemrydi RTU 10 mg.
06Providers: The policy says folic acid and intramuscular vitamin B12 supplementation is started before the first dose and continued through treatment, and corticosteroids are given the day before, the day of, and the day after pemetrexed.
07The policy states that physician administration of vitamin B-12 injections is medically necessary for members receiving pemetrexed, per CPB 0536.
08The recommended non-squamous NSCLC dosing applies to members with creatinine clearance greater than or equal to 45 mL/min.

Codes mentioned

9636596366963679636896379964099641196413964159641696417J9292J9294J9296J9297J9304J9305J9314J9322J9323J9324J9035J9045J9060J9184J9196J9198J9201J9263J9271J9278Q510781291C33C34.92C37C38.4C45.0C45.1C45.2C45.7C48.2C52C53.0C53.9C54.0C54.9C55C56.1C57.02C67.0C67.9C73C83.390C50.011C50.A2C18.0C20C16.0C16.9C25.0C25.9

Original notice

Pemetrexed Products (CPB 0687, reviewed 2026-07-17)
aetna.com · Always check the source before changing claims.
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