← Back to list
State and School Employees' Health Insurance Plan - Monoclonal Antibodies for Treatment of Alzheimer’s Disease
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Leqembi (lecanemab-irmb) may be considered medically necessary when all initial criteria are met, for mild cognitive impairment due to Alzheimer's disease or mild Alzheimer's disease dementia. Kisunla (donanemab-azbt) is considered not medically necessary because other formulary options are covered by the plan for treatment of Alzheimer's disease. The most recent policy revision, dated 07/01/2026, added the Leqembi medically necessary criteria, moved HCPCS J0174 from investigational to medically necessary, and added ICD-10 diagnosis codes G30.0 through G30.9.
Get alerts when payers change rules like this one
We check Blue Cross & Blue Shield of Mississippi and other payers every day and email you when a change matches your specialty and state.
Get Blue Cross & Blue Shield of Mississippi alertsPolicy Monitoring is free. No card required.
What to do
Action · 6 steps
01REQUIREMENTS: Leqembi initial approval needs documentation of a diagnosis of mild cognitive impairment due to Alzheimer's disease or mild Alzheimer's disease dementia based on NIA-AA criteria; positive PET amyloid scan or CSF beta-amyloid assessment; CDR-Global score of 0.5 to 1.0 with Memory Box score of at least 0.5, or MMSE score of 20 to 28, or MoCA score of 18 to 25; a finding that other causes of cognitive impairment or dementia have been ruled out; a baseline brain MRI completed at least 12 months before the requested agent is started; ApoE4 genotype status, or the prescriber's documented counseling that risk cannot be determined; no intracerebral hemorrhage risk factors; no stroke or TIA within the previous 12 months; a stable antithrombotic dose for at least 4 weeks if one is taken; a specialist prescriber or specialist consultation; no FDA-labeled contraindication; and a dose within program quantity limits.
02Initial approval length is 6 months.
03Leqembi renewal needs prior approval through the BCBSMS PA process, the same severity tools used at baseline completed within 30 days before the renewal request, ARIA evaluation on MRI after therapy starts (before the 5th, 7th and 14th infusions), a specialist prescriber or consultation, and a dose within program quantity limits.
04Renewal approval length is 12 months.
05The use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements.
06Kisunla claims, and services for delivering or administering a medication determined not medically necessary, will be considered not medically necessary.
Codes mentioned
J0174J0175G30.0G30.9
Original notice
State and School Employees' Health Insurance Plan - Monoclonal Antibodies for Treatment of Alzheimer’s Disease
bcbsms.com · Always check the source before changing claims.
Related changes
See all Blue Cross & Blue Shield of Mississippi changes →Monoclonal Antibodies for Treatment of Alzheimer’s DiseaseHighNo effective date · Medical PolicySelected Positron Emission Tomography Technologies for Evaluation of Alzheimer DiseaseHighNo effective date · Medical PolicyMagnetic Resonance Imaging (MRI) of the Brain and HeadHighEffective Oct 1, 2026 · Medical PolicyGenetic Testing for Alzheimer DiseaseMediumNo effective date · Medical PolicyBrowse every Blue Cross & Blue Shield of Mississippi change in the policy list