CommercialPrior AuthMedium impact
Mirvetuximab Soravtansine-gynx (Elahere) (CPB 1021, reviewed 2026-01-27)
Aetna·Oncology, OB-GYN·Medical Policy
Effective date
Feb 6, 2023
We identified it
Aug 16, 2026
Summary
Aetna has established coverage criteria for mirvetuximab soravtansine-gynx (Elahere), a folate receptor-alpha targeted therapy for ovarian, fallopian tube, and primary peritoneal cancer. The policy requires precertification for all uses, applies to platinum-resistant disease (with ≥1 prior therapy) and platinum-sensitive disease (with ≥2 prior platinum-based therapies and ≥75% FR-alpha expression), and covers use as monotherapy or in combination with bevacizumab under specific conditions.
Action Required
REQUIREMENTS: Immediately implement precertification requirement for all Aetna commercial members and providers requesting mirvetuximab soravtansine-gynx (Elahere). Billing team must: (1) Update billing system to flag J9063 claims for mandatory prior authorization before submission; (2) Create precertification workflow requiring providers to call (866) 752-7021 or fax (888) 267-3277 with Statement of Medical Necessity (SMN) forms before treatment initiation; (3) Establish documentation checklist to verify coverage criteria met: for platinum-resistant disease confirm ≥1 prior systemic therapy and single-agent or bevacizumab combination use; for platinum-sensitive disease confirm ≥2 prior platinum-based therapies, single-agent use, and ≥75% FR-alpha tumor expression; (4) Train all providers on eligibility criteria and precertification process; (5) Update encounter forms and EMR templates to capture FR-alpha expression testing results and prior therapy history. Claims submitted without prior authorization will be denied. For Medicare beneficiaries, refer to separate Medicare Part B criteria.