Talquetamab-tgvs (Talvey) (CPB 1042, reviewed 2026-05-19)

By 2026-05-19: Billing team and prior authorization staff must implement mandatory precertification workflow for all Talquetamab-tgvs (Talvey) claims. Configure billing system to flag CPT 96401 paired with HCPCS J3055 as requiring precertification before claim submission. Create precertification checklist requiring: (1) verification of diagnosis (C90.00, C90.02, D47.2, or D47.Z9); (2) documentation of prior therapy lines matching Aetna criteria (specific drug categories and minimum counts depending on use case—bridge to CAR-T, single agent, or combination therapy); (3) confirmation of no unacceptable toxicity or disease progression for continuation requests. Update prior authorization submission templates to reference Aetna's three approval pathways (bridge to BCMA CAR-T therapy, single-agent after 4+ lines, or combination with teclistamab). Submit precertification requests to (866) 752-7021 or fax (888) 267-3277 using Statement of Medical Necessity forms from Specialty Pharmacy Precertification portal. Educate oncology providers on eligibility requirements before effective date. Claims submitted without precertification or lacking required prior therapy documentation will be denied. Flag all continuation/reauthorization requests for review of toxicity and disease progression status.