MedicaidPrior AuthMedium impact
Lemtrada® (alemtuzumab) (New)
Humana·OH · Neurology, Pharmacy·Medicaid
Effective date
Dec 1, 2025
We identified it
Aug 4, 2026
Summary
Humana Medicaid Ohio has implemented a new prior authorization policy for Lemtrada (alemtuzumab), a monoclonal antibody for relapsing forms of multiple sclerosis. This is a brand-new policy effective December 1, 2025, requiring prior authorization before dispensing. The drug carries significant safety warnings including black box warnings for autoimmunity, infusion reactions, stroke, and malignancies, and should only be used after inadequate response to two or more MS disease-modifying therapies.
Action Required
By December 1, 2025: Billing and clinical teams must implement prior authorization requirement for Lemtrada (alemtuzumab) HCPCS code J7171 in all Humana Medicaid Ohio claims. (1) Update billing software and prior auth submission protocols to route all Lemtrada claims through the prior authorization process before pharmacy dispensing. (2) Provide prescribers with the single approval criterion: member must have diagnosis of relapsing form of multiple sclerosis (RRMS or active SPMS) with documented inadequate response to two or more MS disease-modifying therapies. (3) Add clinical screening checklist to EMR templates reminding providers of black box warnings and contraindications (active infection, HIV). (4) Train front desk and billing staff that this is a new Ohio Medicaid-specific requirement effective 12/1/2025. (5) Coordinate with specialty/neurology practices to ensure providers submit complete prior auth requests with MS disease history and prior therapy documentation. Claims submitted without prior authorization will be denied. Note: This policy applies to Humana Medicaid Ohio only; verify coverage with other payers separately.