CommercialPrior AuthMedium impact
Talquetamab-tgvs (Talvey) (CPB 1042, reviewed 2026-10-09)
Aetna·Oncology, Hematology·Medical Policy
We identified it
Oct 12, 2026
Summary
Aetna's Clinical Policy Bulletin 1042 (reviewed 2026-10-09) establishes coverage criteria for talquetamab-tgvs (Talvey), a bispecific antibody for relapsed/refractory multiple myeloma and plasma cell-related disorders. The policy requires precertification for all uses and specifies strict treatment history requirements (3-4 prior therapies depending on indication) before approval. Billing teams must verify patient eligibility against these criteria and obtain prior authorization before claims submission.
Action Required
Providers and billing staff must implement the following precertification workflow for all Aetna members: (1) Before submitting claims for talquetamab-tgvs (Talvey), contact Aetna's precertification line at (866) 752-7021 or fax (888) 267-3277 with Statement of Medical Necessity (SMN) forms available at Specialty Pharmacy Precertification; (2) Verify that the patient meets one of the specified criteria: for bridge to CAR-T therapy, at least 3 prior lines including immunomodulatory agent, proteasome inhibitor, and anti-CD38 monoclonal antibody; for single-agent use, at least 4 prior therapies including those same three categories; for combination with teclistamab-cqyv, at least 3 prior therapies; or for POEMS/MIDD/MGRS diagnoses as single agent or in combination; (3) Update billing system templates to flag CPT 96401 and HCPCS J3055 claims for mandatory precertification to prevent denial; (4) Document in the patient's chart the prior treatment history and indication to support medical necessity; (5) Note that this policy applies to commercial medical plans only—for Medicare beneficiaries, refer to Medicare Part B Criteria separately. Without completed precertification, Aetna will deny claims.