J7213 Insurance Policy Changes

Lemtrada® (alemtuzumab) (Revised)

Lemtrada (alemtuzumab) prior authorization requirements were revised effective October 22, 2025 for Humana Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina plans. The policy maintains the requirement that members must have a diagnosis of relapsing-form MS and inadequate response to at least two alternative MS therapies (one must be Ocrevus or Ocrevus Zunovo), with important exceptions noted for Medicare Part D and Medicaid requests where prior Ocrevus treatment does not apply. Billing teams must verify current prior auth criteria before processing claims, as the policy includes complex step-therapy requirements with plan-type specific carve-outs.