CommercialPrior AuthMedium impact
Plozasiran (Redemplo) (CPB 1096, reviewed 12-2026-03)
Aetna·Cardiology, Endocrinology, Genetics +1 more·Medical Policy
Effective date
Dec 3, 2026
We identified it
Aug 13, 2026
Summary
Aetna has issued a new clinical policy (CPB 1096, effective 12-2026-03) establishing coverage criteria for plozasiran (Redemplo), a gene-based therapy for familial chylomicronemia syndrome (FCS) in commercial plans. The policy requires precertification, prescriber specialization (cardiology, endocrinology, lipid specialist, geneticist, or FCS specialist), specific diagnostic confirmation, fasting triglyceride thresholds ≥880 mg/dL, concurrent very-low-fat diet adherence, and prohibition of concurrent use with olezarsen (Tryngolza). All other indications are considered experimental.
Action Required
By December 3, 2026: (1) Billing team must establish precertification routing in billing system for plozasiran (Redemplo) claims. Direct all requests to Aetna GCIT team at (866) 752-7021 or fax (888) 267-3277 before claim submission. (2) Update encounter templates and provider documentation requirements to capture: confirmed FCS diagnosis via genetic testing OR diagnostic scoring (NAFCS ≥45 or Moulin ≥10), baseline fasting triglyceride levels ≥880 mg/dL, current very-low-fat diet adherence (≤20-30g fat/day), and confirmation of no concurrent Tryngolza use. (3) Require providers to document prescriber specialty at time of request (cardiology, endocrinology, lipid specialist, geneticist, or FCS specialist). (4) For continuation of therapy requests: require documentation of positive clinical response (TG reduction or pancreatitis episode reduction) and ongoing diet compliance. (5) Front desk staff must flag any requests for non-FCS indications as experimental/non-covered. Claims submitted without precertification or missing required documentation will be denied. This policy applies ONLY to commercial Aetna plans; refer Medicare beneficiaries to Medicare Part B Criteria.