MedicaidPrior AuthHigh impact
Lemtrada® (alemtuzumab) (Revised)
Humana·OH · Neurology, Pharmacy, Internal Medicine·Medicaid
Effective date
Dec 1, 2025
We identified it
Aug 28, 2026
Summary
Humana Ohio Medicaid has issued a revised Prior Authorization policy for Lemtrada® (alemtuzumab) effective December 1, 2025, with revision date August 26, 2026. The policy establishes that Lemtrada requires prior authorization for Medicaid members with relapsing forms of multiple sclerosis (relapsing-remitting or active secondary progressive disease) and emphasizes it should be reserved for patients with inadequate response to two or more MS drugs. The policy includes critical BLACK BOX warnings regarding autoimmunity, infusion reactions, stroke, and malignancies, with extensive monitoring requirements.
Action Required
By December 1, 2025: Billing and clinical teams must implement prior authorization requirements for all Lemtrada (alemtuzumab) claims for Ohio Medicaid members. Specific actions: (1) Update billing system to flag all Lemtrada claims requiring prior authorization before submission; (2) Coordinate with neurology providers to ensure prescriptions document patient has relapsing form MS (RRMS or active SPMS); (3) Verify prior authorization approval before processing claims; (4) Include documentation of inadequate response to two or more prior MS drugs with authorization requests; (5) Brief front-desk and billing staff that Lemtrada is pharmacy-covered (not medical) and requires pre-authorization. Claims submitted without prior authorization approval will be denied. Providers must also ensure patients meet BLACK BOX monitoring requirements (CBCs, creatinine, urinalysis monthly × 48 months post-infusion; thyroid function every 3 months × 48 months; yearly skin exams). Failure to obtain prior auth will result in claim denials and potential member cost-sharing liability.