Medicare AdvantagePrior AuthHigh impact
Lemtrada® (alemtuzumab) (Revised)
Humana·FL, KY, SC · Neurology, Pharmacy·Medicaid
Effective date
Oct 22, 2025
We identified it
Jun 25, 2026
Summary
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.
Action Required
REQUIREMENTS:
- By November 22, 2025: Billing team must update prior authorization workflows to reflect the October 22, 2025 policy revision for Lemtrada (J7213) in billing software.
- Immediately implement the following prior auth criteria checks before processing claims:
* Verify member has relapsing-form MS diagnosis (RRMS or active SPMS)
* Confirm inadequate response to minimum two alternative MS therapies
* Confirm one therapy was Ocrevus (ocrelizumab) or Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq)
* EXCEPTION: For Medicare Part D and Medicaid requests, do NOT require prior Ocrevus treatment; for Medicare Part B continuation claims within 365 days, step-therapy requirements do not apply
- Update provider documentation templates and prior auth submission forms to specify plan type (Medicare Part B vs. Part D vs. Medicaid) to ensure correct step-therapy criteria are applied.
- Train billing staff and prior authorization specialists on the plan-type-specific exemptions to prevent inappropriate denials.
- Update internal policy reference database to point to Humana's online PA portal (www.humana.com/PAL) for current medical billing codes.
- Establish quarterly review process to monitor Humana policy changes, as this document explicitly states it is updated regularly online and printed versions become uncontrolled.
- Consequences: Claims submitted without proper prior authorization will be denied. Incorrect step-therapy application by plan type will trigger claim rejections and member appeals. Failure to distinguish Medicare Part B/D and Medicaid requirements will result in administrative rework and delayed approvals.