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AetnaCommercial · Prior Auth · Medical Policy · Oncology, Hematology, Rheumatology +7 moreMedium impact

Rituximab (CPB 0314, reviewed 2026-01-08)

Effective date
Not stated in the notice
Identified
Aug 16, 2026

Summary

Aetna Clinical Policy Bulletin 0314 sets the criteria for rituximab products (Rituxan, Truxima, Riabni and Ruxience) and rituximab and hyaluronidase (Rituxan Hycela) for commercial medical plans. For Medicare criteria, the policy refers to the Medicare Part B Criteria. Precertification is required of all Aetna participating providers and members in applicable plan designs. The policy lists initial approval criteria by indication, continuation criteria for members who are experiencing benefit, and the prescriber specialties that must prescribe the medication or be consulted. Aetna considers all other hematologic and oncologic indications, and all other indications not listed, experimental, investigational, or unproven.

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What to do

Action · 9 steps
01Before billing rituximab (Rituxan, Truxima, Riabni or Ruxience) for commercial members, confirm precertification is in place.
02Precertification is required of all Aetna participating providers and members in applicable plan designs, by phone at (1) 752-7021 or by fax at (2) 267-3277, and Statement of Medical Necessity forms are available under Specialty Pharmacy Precertification.
03Confirm that the medication is prescribed by or in consultation with one of the specialties the policy lists for the diagnosis, and that the diagnosis meets the initial approval or continuation criteria for that indication.
04For preferred drugs, refer to the Aetna Commercial Clinical Program Summary.
05Rituxan, Truxima, Riabni and Ruxience are subject to the Utilization Management Policy on Site of Care for Specialty Drug Infusions.
06For rituximab and hyaluronidase (Rituxan Hycela), the member must first have received at least one full dose of a rituximab product by intravenous infusion.
07Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines, and the Medical Specialty Medication Quantity Limits.
08The policy excludes use of these products with any other biologic drug or targeted synthetic drug for rheumatoid arthritis, with other disease modifying multiple sclerosis agents, and with other biologics for neuromyelitis optica.
09Anti-chimeric antibody testing for rituximab therapy is considered experimental, investigational, or unproven.

Codes mentioned

J9312J9311Q5115Q5119Q51239645062350623518352085651856528614086141862008643086431C91.10C82.00C83.30G36.0M31.7L10.0D69.3

Original notice

Rituximab (CPB 0314, reviewed 2026-01-08)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOncologyHematologyRheumatologyNeurologyNephrologyDermatologyOphthalmologyTransplant SurgeryPulmonologyAllergy & ImmunologyCode J9312Code J9311Code Q5115Code Q5119Code Q5123Code 96450Code 62350Code 62351Code 83520Code 85651Code 85652Code 86140Code 86141Code 86200Code 86430Code 86431Code C91.10Code C82.00Code C83.30Code G36.0Code M31.7Code L10.0Code D69.3

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