CommercialCoverageHigh impact
Remdesivir (Veklury) (CPB 0982, reviewed 2026-01-13)
Aetna·Infectious Disease, Critical Care, Internal Medicine +4 more·Medical Policy
Effective date
Jan 13, 2026
We identified it
Aug 15, 2026
Summary
Aetna updated its Remdesivir (Veklury) coverage policy effective January 13, 2026, clarifying that coverage applies ONLY to non-hospitalized, high-risk COVID-19 patients in the outpatient setting with strict criteria including confirmed infection, symptoms within 7 days, high-risk status, hepatic/PT assessment, and a maximum 3-day treatment duration. Hospitalized patients are managed under inpatient benefits. All other indications remain experimental/unproven. Billing teams must ensure claims comply with outpatient-only coverage and document all required criteria.
Action Required
By January 13, 2026: Billing team must implement the following changes: (1) Update billing system to REJECT any Remdesivir (J0248) claims for hospitalized patients—route these to inpatient billing instead. (2) Add system validation to require documentation of all approval criteria: confirmed COVID-19 diagnosis (U07.1 or J12.82), symptom onset within 7 days, high-risk status, patient weight ≥1.5 kg, and non-hospitalized status. (3) Require prior authorization submission to include hepatic function panel (80076) and prothrombin time (85610 or 85611) results obtained before treatment. (4) Configure system to BLOCK claims combining Remdesivir with chloroquine (J0390) or hydroxychloroquine. (5) Limit treatment authorization to maximum 3-day duration per infection episode. (6) Verify all Remdesivir infusions (96365-96368) are billed only in outpatient/office settings with documented ability to manage anaphylaxis. (7) Update encounter templates for providers to document high-risk criteria (chronic lung disease, diabetes, BMI >30, heart conditions, etc.). Claims failing to meet ANY criterion will be denied. Training required for billing, authorizations, and provider teams.