Multiple Sclerosis — CPB 0264 | AETNA Coverage Update

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Aetna modified CPB 0264 for multiple sclerosis drug coverage, effective January 10, 2026. Here's what billing teams need to know.

Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0264 covering multiple sclerosis treatments under commercial medical plans. This revision affects prior authorization requirements and medical necessity criteria for six high-cost infusion drugs — Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, and Tysabri — along with infusion administration codes including CPT 96413–96417 and 96365–96368. If your practice or infusion center bills for any of these agents, this coverage policy change has direct financial exposure.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Multiple Sclerosis — CPB 0264
Policy Code	CPB 0264
Change Type	Modified
Effective Date	January 10, 2026
Impact Level	High
Specialties Affected	Neurology, Infusion Therapy, Specialty Pharmacy, Hematology
Key Action	Verify prior authorization is in place for all six precertification-required MS drugs before billing CPT 96413–96417 or HCPCS J-codes for infusion administration

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Aetna Multiple Sclerosis Coverage Criteria and Medical Necessity Requirements 2026

The Aetna multiple sclerosis coverage policy under CPB 0264 splits treatments across two tracks: drugs that require precertification through Aetna's medical benefit, and drugs managed through pharmacy clinical policy bulletins. Your billing team needs to know which track applies before submitting a claim.

Precertification-required drugs (medical benefit track): Briumvi, Lemtrada (alemtuzumab), Ocrevus, Ocrevus Zunovo, Tyruko, and Tysabri. All six require prior authorization from all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277. Submit Statement of Medical Necessity forms through Aetna's Specialty Pharmacy Precertification portal.

Site of care also matters here. For commercial plans, Aetna's Site of Care Utilization Management Policy applies to all six drugs. This isn't just a documentation issue — it's a reimbursement issue. If your patient receives their infusion in a hospital outpatient department when a lower-cost site is available, expect pushback. Check Aetna's Utilization Management Policy on Site of Care for Specialty Drug Infusions before scheduling.

Alemtuzumab (Lemtrada) Criteria

Lemtrada has the most detailed medical necessity criteria in this policy. Aetna breaks approval into two paths.

First course: The member must have a relapsing form of MS — including relapsing-remitting or secondary progressive MS with ongoing relapses — and must have had an inadequate response to two or more MS drugs. This is a step therapy requirement. Document the prior therapy failures explicitly in your auth request.

Subsequent courses: The member must have completed at least one prior Lemtrada course. The new treatment course must start at least 12 months after the last dose of the prior course. Miss that 12-month window in your documentation and the auth will likely fail.

Concomitant use restriction: Members cannot use Lemtrada with other disease-modifying MS agents. Aetna carves out Ampyra and Nuedexta — neither is considered disease-modifying under this policy, so they don't trigger the restriction.

Pediatric members: Authorization is possible for members under 18 when the treating physician documents that benefits outweigh risks. This is a case-by-case determination, not a blanket exclusion.

Prescriber requirement: Lemtrada must be prescribed by or in consultation with a neurologist. A PCP or internist prescribing alone won't satisfy this criterion. Get the neurology consult note in the chart.

Pharmacy Benefit Track Drugs

Several MS drugs route to Aetna's Pharmacy Clinical Policy Bulletins rather than CPB 0264. These include oral agents — cladribine (Mavenclad), dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), fingolimod (Gilenya), ozanimod (Zeposia), siponimod (Mayzent), teriflunomide (Aubagio) — and self-administered injectables including glatiramer acetate (Copaxone, Glatopa, generic) and ofatumumab (Kesimpta).

The interferons — interferon beta-1a (Rebif), interferon beta-1b (Betaseron, Extavia), and peginterferon beta-1a (Plegridy) — also route to separate pharmacy bulletins. Don't bill these through the medical benefit without confirming the correct policy applies.

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Aetna Multiple Sclerosis Exclusions and Non-Covered Indications

Several procedures and diagnostics appear in CPB 0264 specifically as non-covered for MS. These are worth auditing against your current charge capture.

Plasma pheresis (CPT 36514) is not covered for chronic or secondary progressive MS. If you're billing this for an MS patient, confirm the indication is something other than chronic or secondary progressive disease — or expect a claim denial.

Hematopoietic stem and progenitor cell measurements using CD34 total count (CPT 86367) are not covered for this indication. The code appears in the policy but with an explicit exclusion note.

Alemtuzumab for any indication outside relapsing MS — Aetna considers all other uses experimental, investigational, or unproven. Don't attempt to build a case for off-label use here. The policy is explicit.

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Coverage Indications at a Glance

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Aetna Multiple Sclerosis Billing Guidelines and Action Items 2026

Multiple sclerosis billing for these agents is high-dollar and high-scrutiny. A single missing auth or a wrong site-of-care code can kill a five-figure claim. Here's what to do now.

Copy Action Items

If you're unsure how the site of care policy or step therapy documentation requirements apply to your specific patient mix, talk to your compliance officer before the effective date.

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CPT, HCPCS, and ICD-10 Codes for Multiple Sclerosis Under CPB 0264

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental Codes

Administration and Infusion CPT Codes (Related to CPB)

HCPCS Codes

Code	Type	Description Copy
J0881	HCPCS	Injection, darbepoetin alfa, 1 mcg (non-ESRD use)
J0885	HCPCS	Injection, epoetin alfa (for non-ESRD use), 100 units
J0888	HCPCS	Injection, epoetin beta, 1 microgram (for non-ESRD use)

The policy data for CPB 0264 does not include ICD-10-CM diagnosis codes in the code table. Reference your payer's remittance documentation for applicable MS diagnosis coding.

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