Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Alemtuzumab (Lemtrada) may be considered medically necessary for the treatment of relapsing-remitting forms of MS when the following criteria are met:
- ONE of the following:
- Information has been provided that the individual has been treated with alemtuzumab (Lemtrada) the within the past 90 days; or
- The prescriber states the individual has been treated with alemtuzumab (Lemtrada) within the past 90 days AND is at risk if therapy is changed; or
- BOTH of the following:
- The individual has a diagnosis of relapsing forms of MS as defined by an MRI of the brain showing abnormalities consistent with MS; and
- The individual has had an inadequate response to TWO or more preferred medications indicated for the treatment of MS OR the individual has a documented intolerance, FDA labeled contraindication, or hypersensitivity to ALL preferred medications; and
- The prescriber is a specialist in the area of the individual’s diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
- The individual has HIV-negative status; and
- The individual will not use alemtuzumab (Lemtrada) in combination with other disease modifying therapies (DMTs); and
- The individual receives appropriate vaccinations, concomitant prophylaxis, and pre-infusion medications:
- High dose corticosteroids prior to infusion and for first 3 days of each treatment course; and
- Anti-viral prophylaxis for herpetic viral infections; and
- Completion of any necessary immunizations at least 6 weeks prior to treatment with alemtuzumab (Lemtrada), with no live vaccines administered concurrent or within 6 weeks prior to treatment.
Avonex® (interferon β-1a)
Betaseron® (interferon β-1b)
Alemtuzumab (Lemtrada) is considered experimental/investigational, and therefore, non-covered for all other indications. Scientific evidence does not support its use for any other indication.