CommercialPrior AuthHigh impact
Isatuximab-irfc (Sarclisa) (CPB 0969, reviewed 2026-03-02)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Mar 2, 2026
We identified it
Aug 15, 2026
Summary
Aetna has updated its clinical policy for Isatuximab-irfc (Sarclisa) effective immediately, expanding coverage criteria to include multiple myeloma treatment across five distinct combination therapy regimens and adding coverage for POEMS syndrome, MIDD, and MGRS. All Sarclisa administration now requires mandatory precertification before treatment begins.
Action Required
By March 2, 2026: Billing team must implement mandatory precertification workflow for ALL Sarclisa (J9227) claims. 1) Update prior authorization system to flag every Sarclisa request for precertification before claim submission. 2) Configure system to require one of five approved multiple myeloma combination regimens OR approved diagnosis (POEMS, MIDD, MGRS) with ICD-10 codes C90.00-C90.02, D47.2, or D47.Z9. 3) Add precertification phone number (866-752-7021) and fax (888-267-3277) to billing staff reference materials. 4) Train billing team that claims for experimental combinations (isatuximab + atezolizumab, isatuximab + cemiplimab, isatuximab alone for lymphoma, acute lymphoblastic leukemia, Duchenne muscular dystrophy, light chain amyloidosis, soft tissue plasmacytoma) will be denied. 5) Providers must submit Statement of Medical Necessity (SMN) forms to Specialty Pharmacy Precertification. Failure to obtain precertification will result in claim denials and member liability.