Description: Injection, alemtuzumab
Unit: 1 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 12mg IV every day for 5 days
• 12mg IV every day for 3 days, 12 months after previous dosage
Calculate drug reimbursement
(ASP: $129,779.43, Margin: $7,786.77)
# Units to bill:60
Prior auth criteria for Lemtrada may include but is not limited to:
• Diagnosis of relapsing forms of multiple sclerosis (MS) including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.
• The patient has failed to achieve disease control with at least 2 disease-modifying therapies (DMTs).
• The patient has a documented history of confirmed relapses or MRI evidence of disease activity within the last 12 months.
• The patient is not pregnant or breastfeeding.
• The patient is not eligible for other DMTs with proven efficacy.
• The patient has no active infections or other medical conditions that could interfere with the efficacy of the treatment.
• The patient has a body weight >50kg.
• The patient has normal renal function.
• The patient has normal hepatic function.
• The patient has normal CBC values.
• The patient has normal thyroid function tests.
• The patient has normal urinalysis.
• The patient has been counseled about the potential risks and benefits of Lemtrada treatment.
Insurance prior auth guidelines:
LEMTRADA (GENZYME CORPORATION)