CommercialPrior AuthHigh impact
Lecanemab-irmb (Leqembi) (CPB 1026, reviewed 2026-01-27)
Aetna·Neurology, Psychiatry, Geriatrics +1 more·Medical Policy
Effective date
Jan 27, 2026
We identified it
Aug 16, 2026
Summary
Aetna has updated its coverage policy for Lecanemab-irmb (Leqembi), an Alzheimer's disease treatment, effective immediately. This policy establishes strict precertification requirements, detailed eligibility criteria including cognitive staging and biomarker confirmation, mandatory MRI monitoring protocols, and restrictions on concurrent medications. All providers must enroll members in an approved Alzheimer's disease registry (e.g., ALZ-NET) for initial approval and continuation of therapy.
Action Required
Immediately: (1) Establish precertification workflow - all Leqembi requests require prior authorization via phone (866-752-7021) or fax (888-267-3277) before treatment initiation. (2) Billing team must update eligibility checklist to verify: member age 50+, Clinical Stage 3-4 AD, baseline cognitive assessment scores (CDR-GS 0.5-1, MMSE 21-30, or MoCA ≥16), biomarker confirmation (PET scan or CSF results), recent MRI (within 1 year), ApoE ε4 genotype testing, and absence of exclusion criteria. (3) Verify prescriber is geriatrician, neurologist, psychiatrist, or neuropsychiatrist before authorization. (4) Confirm member/provider enrollment in approved registry (ALZ-NET) - no approval without registry participation. (5) Document drug interaction screening: PROHIBIT concurrent use of anticoagulants (warfarin, heparin, DOACs); limit antiplatelet agents to monotherapy at standard dose only. (6) Update claim submission to reference Site of Care Utilization Management Policy for specialty drug infusions. (7) For continuation at 12 months: require repeat MRI assessment at doses 3, 5, 7, and 14 with ARIA-E and ARIA-H protocols documented; track clinical response using same baseline assessment tool. (8) Train front desk staff to inform patients about registry enrollment requirement during scheduling. Failure to obtain precertification or meet enrollment requirements will result in claim denials.