Inebilizumab-cdon (Uplizna) (CPB 0975, reviewed 2026-08-11)

Immediately: Billing and authorization teams must implement precertification workflow for all Aetna members requesting inebilizumab-cdon (Uplizna). Route all precertification requests to (866) 752-7021 or fax (888) 267-3277. Update billing system to flag HCPCS code J1823 for mandatory prior authorization. Before claim submission, verify documentation includes: (1) For NMOSD: anti-aquaporin-4 antibody positivity (CPT 86051, 86052, or 86053) AND one core clinical characteristic; (2) For IgG4-RD: clinical diagnosis confirmed by radiologic/pathologic evidence, recent IgG4-RD flare requiring glucocorticoid (within 4 weeks), and multi-organ involvement history; (3) For gMG: anti-AChR or anti-MuSK antibody positivity (CPT 86041, 86042, 86043, or 86366) AND MGFA classification II-IV AND MG-ADL score ≥5 AND documented failed prior therapies. Ensure prescribing specialty restrictions are enforced (neurologist for NMOSD/gMG, rheumatologist for IgG4-RD). Deny claims submitted without precertification or missing required clinical documentation. Update encounter forms and EMR templates to capture all required clinical criteria. Train providers on site of service requirements per Utilization Management Policy on Site of Care for Specialty Drug Infusions.