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AetnaAll Plans · Prior Auth · Medical Policy · Rheumatology, Dermatology, Oncology +1 moreMedium impact

Etanercept (CPB 0315, reviewed 2026-07-08)

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

Summary

Aetna's Clinical Policy Bulletin 0315 considers etanercept (Enbrel) medically necessary for rheumatoid arthritis, articular juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, plaque psoriasis, reactive arthritis, hidradenitis suppurativa, graft versus host disease, Behcet's disease and immune checkpoint inhibitor-related toxicity when the listed criteria are met. Initial criteria differ by indication and include prior treatment with other drugs for several of them, and continuation of therapy requires a positive clinical response. Aetna considers all other indications experimental, investigational, or unproven, including concomitant use with another biologic or targeted synthetic drug for the same indication.

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What to do

Action · 9 steps
01Etanercept must be prescribed by or in consultation with the specialist listed for each indication: a rheumatologist for rheumatoid arthritis, articular juvenile idiopathic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, reactive arthritis and Behcet's disease; a rheumatologist or dermatologist for psoriatic arthritis and hidradenitis suppurativa; a dermatologist for plaque psoriasis; an oncologist or hematologist for graft versus host disease; an oncologist, hematologist or rheumatologist for immune checkpoint inhibitor-related inflammatory arthritis; and an oncologist, hematologist or dermatologist for immune checkpoint inhibitor-related toxicity.
02Document a negative tuberculosis test (a skin test or an interferon-release assay) within 12 months of initiating therapy for members who are new to biologic or targeted synthetic drugs associated with an increased risk of TB.
03If the screening test is positive, complete further testing to confirm there is no active disease, such as a chest x-ray.
04Do not give the requested medication to members with active TB infection, and if latent disease is present, TB treatment must be started before initiation.
05Confirm the member is not using any other biologic drug or targeted synthetic drug for the same indication.
06Dose optimization with 50 mg product formulations should be used when possible.
07Exceptions for higher quantities of 25 mg vials are allowed when the member has a latex allergy or is following FDA-approved weight-based dosing.
08Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia and/or evidence-based practice guidelines.
09For continuation of therapy in rheumatoid arthritis, document at least 20% improvement from baseline in tender joint count, swollen joint count, pain, or disability.

Codes mentioned

J1438D89.9L40.4L40.8L40.9L40.50L40.59L73.2M00.00M01.X9M02.30M02.9M05.00M06.9M08.00M08.9AM35.2M45.0M45.9T45.AX5AT45.AX5S

Original notice

Etanercept (CPB 0315, reviewed 2026-07-08)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesRheumatologyDermatologyOncologyHematologyCode J1438Code D89.9Code L40.4Code L40.8Code L40.9Code L40.50Code L40.59Code L73.2Code M00.00Code M01.X9Code M02.30Code M02.9Code M05.00Code M06.9Code M08.00Code M08.9ACode M35.2Code M45.0Code M45.9Code T45.AX5ACode T45.AX5S

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