CommercialPrior AuthMedium impact
Tebentafusp-tebn (Kimmtrak) (CPB 1005, reviewed 2026-04-09)
Aetna·Oncology, Ophthalmology·Medical Policy
Effective date
Apr 9, 2026
We identified it
Aug 17, 2026
Summary
Aetna has established a new clinical policy for tebentafusp-tebn (Kimmtrak), a bispecific T-cell engager for treating HLA-A*02:01-positive patients with unresectable or metastatic uveal melanoma. The policy requires precertification for all claims and covers specific HCPCS and ICD-10 codes when medical necessity criteria are met. This is a brand-new policy effective immediately with no grandfathered exceptions.
Action Required
By April 9, 2026: Billing team must implement precertification requirements for all tebentafusp-tebn (Kimmtrak) claims through Aetna. (1) Update billing system to flag CPT codes 96413-96417 and 96365-96368 paired with HCPCS code J9274 as requiring mandatory prior authorization. (2) Configure system to require HLA-A*02:01 positive status verification before claim submission. (3) Establish precertification workflow requiring providers to call (866) 752-7021 or fax (888) 267-3277 before treatment initiation. (4) Add ICD-10 codes C69.30-C69.32 and C69.40-C69.42 (unresectable/metastatic uveal melanoma only) to approved diagnosis codes for coverage. (5) Train billing and clinical staff that tebentafusp-tebn is only covered for uveal melanoma; all other indications are considered experimental/investigational and will be denied. (6) Implement monitoring for reauthorization requests; continuation of therapy requires documentation of no unacceptable toxicity or disease progression. Failure to obtain precertification will result in claim denials for this specialty pharmaceutical.