CommercialPrior AuthHigh impact
Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Jul 16, 2026
We identified it
Aug 15, 2026
Summary
Aetna has published a comprehensive update to its Ipilimumab (Yervoy) clinical policy (CPB 0815, effective 2026-07-16) establishing detailed coverage criteria for this immunotherapy drug across 25+ cancer indications. The policy requires precertification for all uses and mandates trial of lower-cost alternatives where applicable. Billing teams must implement prior authorization workflows and ensure claims align with specific indications, combination therapy requirements, and biomarker criteria (TMB-H, MSI-H, dMMR, etc.).
Action Required
By 2026-07-16: (1) Billing and precertification teams must implement mandatory precertification workflow for all Ipilimumab (Yervoy) claims via phone (866) 752-7021 or fax (888) 267-3277. (2) Update billing system to validate that each claim matches one of the 25+ approved indications and meets all specific criteria (e.g., TMB-H ≥10 mut/Mb for certain cancers, MSI-H/dMMR status, combination with nivolumab dosing specifics). (3) Create billing team checklist/prompt requiring: indication verification, biomarker documentation confirmation, combination therapy verification, and site-of-care utilization management compliance. (4) Update prior authorization forms to reference Aetna's Specialty Pharmacy Precertification forms and Site of Care utilization policy. (5) Ensure providers submit Statement of Medical Necessity (SMN) with all precertification requests. (6) Implement requirement for documentation of trial of lower-cost preferred alternatives per Aetna Commercial Clinical Program Summary before approving Yervoy claims. Failure to obtain precertification will result in claim denials. Incorrect indication or missing biomarker documentation will delay approval.