CommercialPrior AuthMedium impact
ADAMTS13, Recombinant-krhn (Adzynma) (CPB 1050, reviewed 2025-12-03)
Aetna·Hematology, Pediatrics, Internal Medicine +1 more·Medical Policy
Effective date
Dec 3, 2025
We identified it
Aug 17, 2026
Summary
Aetna has established a new clinical policy (CPB 1050, effective 2025-12-03) covering ADAMTS13, recombinant-krhn (Adzynma) for congenital thrombotic thrombocytic purpura (cTTP) treatment. Coverage requires precertification, genetic testing confirmation of biallelic ADAMTS13 mutations, and ADAMTS13 activity <10% at diagnosis. Billing teams must implement prior authorization requirements and update systems to handle this specialty infusion drug.
Action Required
By 2025-12-03: Billing team must implement precertification requirements for all Adzynma (J7171) claims. (1) Update billing system to require prior authorization before claim submission; (2) Create encounter form prompts requiring provider documentation of: genetic testing confirmation with biallelic ADAMTS13 mutations AND ADAMTS13 activity level <10% at diagnosis; (3) Configure system to route all J7171 claims to precertification team; (4) Establish precertification contact protocol: call (866) 752-7021 or fax (888) 267-3277 with Statement of Medical Necessity (SMN) forms via Specialty Pharmacy Precertification; (5) Apply Site of Care Utilization Management Policy for infusion location determination; (6) Train front-desk, billing, and prior-auth staff on cTTP diagnosis requirements and specialty drug protocols. Failure to obtain precertification will result in claim denials. All applicable plan designs require precertification per policy.