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AetnaCommercial · Prior Auth · Medical Policy · Oncology, UrologyMedium impact

Enfortumab Vedotin-ejfv (Padcev) (CPB 0967, reviewed 2026-04-24)

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

Summary

Aetna Clinical Policy Bulletin 0967 covers enfortumab vedotin-ejfv (Padcev) for commercial medical plans and requires precertification for all Aetna participating providers and members in applicable plan designs. Aetna considers Padcev medically necessary for urothelial carcinoma as a single agent when it is used as subsequent therapy after platinum-containing chemotherapy and a PD-1 or PD-L1 inhibitor, or as subsequent therapy for members who are ineligible for cisplatin-containing chemotherapy, in the listed bladder, upper genitourinary tract, and prostate settings, and in combination with pembrolizumab or pembrolizumab and berahyaluronidase alfa-pmph for stage II, recurrent, locally advanced, or metastatic urothelial carcinoma. Aetna considers all other indications experimental, investigational, or unproven.

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What to do

Action · 5 steps
01REQUIREMENTS: Billing team: Obtain precertification for Padcev by calling (866) 752-7021 or faxing (888) 267-3277, and use the Statement of Medical Necessity precertification forms listed under Specialty Pharmacy Precertification.
02Providers: Confirm the member meets one of the listed indications and criteria, because Aetna considers Padcev medically necessary only when the criteria are met.
03Billing team: HCPCS J9177 (enfortumab vedotin-ejfv, 0.25 mg) is listed as covered if the selection criteria are met.
04Billing team: ICD-10 codes C64.1, C64.9, C65.1, C65.9, C66.1, C66.9, C67.0, C67.9, C68.0 and C68.9 are listed as covered if the selection criteria are met.
05Billing team: Continuation of therapy is considered medically necessary for reauthorization when there is no evidence of unacceptable toxicity or disease progression on the current regimen.

Codes mentioned

522045221452224522345223552240773997741777427774999641396416J9177J9022J9023J9045J9060J9173J9263J9271J9299C64.1C64.9C65.1C65.9C66.1C66.9C67.0C67.9C68.0C68.9

Original notice

Enfortumab Vedotin-ejfv (Padcev) (CPB 0967, reviewed 2026-04-24)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOncologyUrologyCode 52204Code 52214Code 52224Code 52234Code 52235Code 52240Code 77399Code 77417Code 77427Code 77499Code 96413Code 96416Code J9177Code J9022Code J9023Code J9045Code J9060Code J9173Code J9263Code J9271Code J9299Code C64.1Code C64.9Code C65.1Code C65.9Code C66.1Code C66.9Code C67.0Code C67.9Code C68.0Code C68.9

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