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Lemtrada (Alemtuzumab)


Billing

Code: J0202

Description: Injection, alemtuzumab

Unit: 1 mg

Payment: $2292.770

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Multiple Sclerosis (MS)

Induction:
• 12mg IV every day for 5 days

Maintenance:
• 12mg IV every day for 3 days, 12 months after previous dosage

Calculate drug reimbursement


Total Reimbursement:

$137,566.20

(ASP: $129,779.43, Margin: $7,786.77)


Code:

J0202

# Units to bill:

60

Prior Authorization

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:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

58468-0200-01

LEMTRADA (GENZYME CORPORATION)

12 MG



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