CareCost Prior authorization
Required
Check what the payer requires before you schedule Kisunla.
20 payers, 186 rules, and 3 of them require Leqembi first.
20 payer policy sets hold a donanemab-azbt policy · source-linked · reviewed August 2026
Aetna + MCI due to Alzheimer's is shown as a live example until you choose a payer.
This payer requires an approval on file before Kisunla is purchased or infused for this member.
Precertification of donanemab-azbt (Kisunla) is required of all Aetna participating providers and members in applicable plan designs.
Covered under ICD-10 G30, G31.84.
Aetna considers donanemab-azbt (Kisunla) medically necessary for treatment of Alzheimer's Disease (AD)
The policy names the dose and frequency it pays for.
Infusion 4 and beyond: 1,400 mg
What opens in CareCost
Aetna · Kisunla · MCI due to Alzheimer's
For every requirement: the exact payer criteria, the source citation, a check-off, and a save to the patient’s chart.
In CareCost: check off each requirement · save to the patient · print for the chart
Aetna · Kisunla · MCI due to Alzheimer's
You have already checked the policy, indication and covered dose. Open the remaining requirements and work them as a patient checklist.
CareCost tracks Kisunla coverage requirements across 20 payer policy sets.
Aetna · Anthem / Elevance · UnitedHealthcare · Kaiser Permanente WA · CareFirst BCBS · BCBS plans + more
Coverage clearance is only the first step.
CareCost carries the same patient through the entire workflow.
Finish this patient’s estimate →15 of 20 commercial payers with a donanemab-azbt policy require prior authorization. Every payer in this corpus documents confirmed amyloid pathology, a cognitive-stage diagnosis and a baseline MRI before Kisunla is covered; reauthorization timing and quantity limits vary by plan.
The 186 rules break out as 107 clinical prerequisites, 20 covered-indication rules (one per payer, since Kisunla’s two ICD-10s share a single clearance key), 15 prior-authorization rules, 15 contraindication exclusions, 12 quantity limits, 7 dosing rules, 6 reauthorization rules and 4 site-of-care rules.
15 require PA · 20 have clinical criteria · 4 restrict site of care
15 of the 20 payers CareCost has read require an approval on file before donanemab-azbt is covered. Aetna’s precertification rule reads: “Precertification of donanemab-azbt (Kisunla) is required of all Aetna participating providers and members in applicable plan designs.” The other 5 apply the same clinical review without a formal prior-authorization label; the documentation burden is the same either way.
Every payer in this corpus applies the same shape of requirement before it pays: confirmed amyloid pathology (PET or CSF), a diagnosis at the mild cognitive impairment or mild dementia stage, the population Kisunla’s label restricts treatment to, and a baseline brain MRI before the first infusion. Aetna’s covered-indication rule states it plainly: “Aetna considers donanemab-azbt (Kisunla) medically necessary for treatment of Alzheimer's Disease (AD).” BCBS Massachusetts adds a fourth condition: the patient must not be “currently receiving and has not previously received another anti-amyloid monoclonal antibody.” That same clause also makes Massachusetts one of the three payers requiring a different product first.
3 of the 20 payers in this corpus will not approve Kisunla until Leqembi has been tried, failed or ruled out. Florida Blue: “Member has been previously receiving lecanemab-irmb (Leqembi) therapy for AD.” BCBS Minnesota: “Patient must have a contraindication, intolerance, or failure to Leqembi prior to the consideration of Kisunla.” BCBS Massachusetts: “Not currently receiving and has not previously received another anti-amyloid monoclonal antibody.” The other 17 payers in this corpus do not name a required product ahead of Kisunla.
12 of the 186 rules in this corpus cap the amount or the authorization period, and they split into two shapes. Five cap the milligrams: Premera, “The maintenance dose is limited to 1,400 mg every 4 weeks.” Anthem, “4 vials (80 mL) per 4 weeks” (the same maintenance dose, stated in vials). Centene, “1,400 mg every 4 weeks.” Capital BlueCross, “Infusion 4 and beyond: 700 billable units every four weeks thereafter” (700 units of 2 mg each is the same 1,400 mg ceiling). Regence: “Kisunla (donanemab) Doses up to 1400 mg every 4 weeks.” Every one of the five matches Kisunla’s own labeled maintenance schedule; none of them cut the dose below what the FDA label allows. The other seven quantity-limit rules cap the authorization period instead of the milligrams, and read like the reauthorization rules below.
Renewal timing varies more than anything else in this corpus. CareFirst and BCBS Tennessee open with a 7-month authorization, then extend to 12 months at the first renewal: “Authorization of 12 months (first reauthorization after the initial 7-month approval period) may be granted for members requesting continuation of therapy.” UnitedHealthcare caps its initial period at 12 months outright: “Initial authorization will be for no more than 12 months.” Kaiser reviews continuation every 12 months. Capital BlueCross renews annually after the first approval: “Prior authorization validity may be renewed annually thereafter.” BCBS South Carolina ties continuation to the same diagnosis staying on the chart: “Continuation of Kisunla may be considered MEDICALLY NECESSARY when all of the following criteria have been met… Patient continues to have one of the following diagnoses.” BCBS HCSC ties renewal to documented improvement: “Individual has a positive clinical response as evidenced by improvement or stabilization in score in any of the following measures.”
4 of the 20 payers in this corpus touch where the infusion happens, and none of them limit Kisunla to a single setting outright. Aetna: “Site of Care Utilization Management Policy applies.” Arkansas BCBS points to a separate review: “…refer to separate policy on Site of Care or Site of Service Review (policy #2018030) for pharmacologic/biologic medications.” Blue Shield of California lists every setting it will cover: infusion center, home infusion, office and outpatient facility administration.
Donanemab-azbt and lecanemab-irmb are both anti-amyloid antibodies for early symptomatic Alzheimer's, billed under their own J-code, and a payer may require one before the other.
| Product | Code | Maker | On this page |
|---|---|---|---|
| Kisunla | J0175 | Eli Lilly | This page |
| Leqembi | J0174 | Eisai / Biogen | Required first at 3 of 20 payers |
CareCost reads 20 payer policies for each drug. 3 of the 20 covering Kisunla require Leqembi first: Florida Blue, BCBS Minnesota and BCBS Massachusetts, quoted above. Only one payer runs a comparable rule in the other direction: BCBS Massachusetts excludes a patient who has “previously received another anti-amyloid monoclonal antibody” from starting Leqembi, the same clause that also blocks a Kisunla start without Leqembi first.
Both drugs carry the same boxed warning, amyloid related imaging abnormalities (ARIA-E, ARIA-H), with MRIs scheduled around the early infusions of either one. Both bill their infusion with 96365 (therapeutic infusion), never 96413 (chemotherapy administration), the wrong code family for a non-oncology monoclonal antibody. Neither fact changes which product a payer requires first; it only means the monitoring and billing pattern is the same once a patient is on either drug.
Every payer in this corpus that covers Kisunla still requires confirmed amyloid pathology and the diagnosis codes below regardless; the Leqembi-first requirement is layered on top of that prerequisite, not a replacement for it.
Kisunla’s manifest carries two billable indications, and both share the same dxKey, alzheimers_disease_early_symptomatic, so every payer’s donanemab-azbt rule applies the same way regardless of which one is on the claim.
| Indication | ICD-10 | Notes |
|---|---|---|
| Mild cognitive impairment due to Alzheimer's disease, with confirmed amyloid pathology | G31.84 | Billable code; dxKey alzheimers_disease_early_symptomatic |
| Mild Alzheimer's disease dementia, with confirmed amyloid pathology | G30.9 | Billable code; same dxKey as above |
CareCost’s diagnosis picker above offers both. Verified against the NLM Clinical Table Search Service on 2026-09-20.
Medicare pays for Kisunla under NCD 200.3, coverage with evidence development. The prescriber must enroll the patient in a CMS-approved registry (CareCost’s own reference page names ALZ-NET as the registry most commonly used) and document the amyloid result that made the patient eligible. No registry, no payment: the CMS Medicare Coverage Database record for J0175 requires both pieces on file before the Part B claim is paid.
This is the Original Medicare answer. A Medicare Advantage plan administers the same Part B benefit but can layer its own prior-authorization and site-of-care rules on top. Check the plan’s own policy rather than assuming the Original Medicare rules carry over.
Kisunla is a 30-minute infusion billed with 96365 (therapeutic infusion, initial hour) alone, non-facility PFS $67.14; 96366 (each additional hour) does not apply at this infusion length, and 96413 (chemotherapy administration) is the wrong code family for an anti-amyloid antibody. There is no push option and no documented-time threshold to track: every Kisunla infusion bills the same code.
Payer citation language above is drawn from CareCost’s own donanemab-azbt policy corpus (20 payers, 186 rules). Check the specific payer’s language →
It depends on the payer and plan. 15 of the 20 donanemab-azbt policies CareCost has read require prior authorization before Kisunla is covered. The other 5 apply the same clinical review without a formal prior-authorization label; the documentation burden is the same either way. Check this patient’s payer →
Confirmed amyloid pathology, a diagnosis at the mild cognitive impairment or mild dementia stage, and a baseline brain MRI, at every payer in this corpus. 3 of the 20 (Florida Blue, BCBS Minnesota and BCBS Massachusetts) also require Leqembi first. Check this patient’s payer →
Yes, under NCD 200.3, coverage with evidence development. The prescriber must enroll the patient in a CMS-approved registry (ALZ-NET is the one CareCost’s own reference page names) and document the amyloid result that made the patient eligible. No registry, no payment. See the Medicare detail →
Coverage with evidence development under NCD 200.3 means Medicare pays for Kisunla (J0175) only when the prescriber has enrolled the patient in a CMS-approved registry and documented the amyloid result. The Kisunla reference page names ALZ-NET as the registry most commonly used. No registry, no payment. See the Medicare detail →
Yes, at 3 of the 20 payers in this corpus. Florida Blue: “Member has been previously receiving lecanemab-irmb (Leqembi) therapy for AD.” BCBS Minnesota: “Patient must have a contraindication, intolerance, or failure to Leqembi prior to the consideration of Kisunla.” BCBS Massachusetts: “Not currently receiving and has not previously received another anti-amyloid monoclonal antibody.” Check this patient’s payer →
It varies by payer. CareFirst and BCBS Tennessee open with a 7-month authorization, then extend to 12 months at the first renewal. UnitedHealthcare caps the initial authorization at 12 months. Kaiser reviews continuation every 12 months. Check this patient’s payer →
Data current: payer policies Aug 2026 · reviewed dates come from each payer
Payer medical and pharmacy policies · prior-authorization criteria · clinical coverage criteria. ICD-10 codes verified against the NLM Clinical Table Search Service. Medicare coverage and fee-schedule amounts from the CMS Medicare Coverage Database and the Medicare Physician Fee Schedule. Every CareCost requirement links back to its source policy.