Alemtuzumab (Lemtrada)

Alemtuzumab (Lemtrada) is covered only for the FDA‑approved indication of relapsing forms of multiple sclerosis in patients ≥17 years when prescribed by or in consultation with an MS specialist and is excluded for non‑relapsing/progressive‑only forms, patients <17, or non‑FDA uses. Key requirements: documentation of diagnosis and prescriber specialty, prior inadequate response/intolerance to two disease‑modifying therapies or evidence of highly active/aggressive disease (clinical/MRI criteria), initial approval limited to 12 mg/day × 5 days and reauthorization to 12 mg/day × 3 days only if ≥12 months have elapsed with prior Lemtrada treatment dates documented.

"FDA-approved indication: Multiple Sclerosis (MS)"

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