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Mirvetuximab Soravtansine-gynx (Elahere) (CPB 1021, reviewed 2026-01-27)
Effective date
Feb 6, 2023
Identified
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.
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What to do
Action · 9 steps
01REQUIREMENTS: Immediately implement precertification requirement for all Aetna commercial members and providers requesting mirvetuximab soravtansine-gynx (Elahere).
02Billing team must.
03Update billing system to flag J9063 claims for mandatory prior authorization before submission.
04Create precertification workflow requiring providers to call (866) 752-7021 or fax (888) 267-3277 with Statement of Medical Necessity (SMN) forms before treatment initiation.
05Establish 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.
06Train all providers on eligibility criteria and precertification process.
07Update encounter forms and EMR templates to capture FR-alpha expression testing results and prior therapy history.
08Claims submitted without prior authorization will be denied.
09For Medicare beneficiaries, refer to separate Medicare Part B criteria.
Codes mentioned
963659636696367963689641396414964159641696417J9063C9257J9035J9045J9060J9263C48.0C48.1C48.2C48.8C56.1C56.9C57.00C57.01C57.02
Original notice
Mirvetuximab Soravtansine-gynx (Elahere) (CPB 1021, reviewed 2026-01-27)
aetna.com · Always check the source before changing claims.
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