Leqembi (lecanemab-irmb) — HCPCS J0174
CareCost Estimate · Billing Cheat Sheet
Eisai Inc. (co-marketed Biogen)
200 mg/2 mL & 500 mg/5 mL single-dose vials
IV ~1 hr every 2 weeks
Reviewed: May 2, 2026
ASP: Q2 2026
Dose
10 mg/kg
IV q2wk · weight-based
Modifiers
JZ + JW
Waste common
Admin CPT
96365
+96366 · non-chemo IV
ASP+6%
$1.336
/mg · $935.20/70 kg
BOXED WARNING — ARIA: Amyloid-related imaging abnormalities (ARIA-E vasogenic edema, ARIA-H microhemorrhages & superficial siderosis). APOE4 homozygotes have substantially higher risk including symptomatic ARIA. tPA contraindicated; anticoagulant caution. Permanently d/c for severe ARIA.
Codes & NDC
| HCPCS | J0174 — "Inj, lecanemab-irmb, 1 mg" (permanent; pre-permanent used J3490) |
|---|
| NDC (representative) | 62856-0270-01 (200 mg) / 62856-0271-01 (500 mg) — verify carton NDC; N4 qualifier |
|---|
| Vials | 200 mg / 2 mL and 500 mg / 5 mL (100 mg/mL) single-dose |
|---|
| Sister drug | Kisunla (donanemab-azbt, J0175) — Lilly, q4wk fixed dose |
|---|
| Benefit | Medical (provider buy-and-bill); SP distribution in some markets |
|---|
Dosing
- 10 mg/kg IV over ~1 hour, every 2 weeks (no loading)
- ~26 doses/year; treatment indefinite until past mild dementia
- 1-hr observation post-infusion (esp. first 4 doses)
- Year-1 70 kg patient: 18,200 units (26 × 700)
Vial math — bill JZ vs JW
| Wt (kg) | Dose (mg) | Vials | Waste | Mod |
|---|
| 50 | 500 | 1 × 500 | 0 | JZ |
| 60 | 600 | 1 × 500 + 1 × 200 | 100 | JW |
| 70 | 700 | 1 × 500 + 1 × 200 | 0 | JZ |
| 75 | 750 | 1 × 500 + 2 × 200 | 150 | JW |
| 80 | 800 | 1 × 500 + 2 × 200 | 100 | JW |
| 90 | 900 | 1 × 500 + 2 × 200 | 0 | JZ |
| 100 | 1,000 | 2 × 500 | 0 | JZ |
MRI surveillance schedule
| When | Required? |
|---|
| Baseline (within 1 yr pre-tx) | Required |
| Before dose 5 | Required |
| Before dose 7 | Required |
| Before dose 14 | Required |
| Symptom-triggered (any dose) | As clinically indicated |
CPT 70551 (no contrast) or 70553 (with & without). 4+ MRIs year 1 minimum.
Administration & modifiers
| Code | When |
|---|
96365 | Therapeutic IV, initial 1 hr (primary) — non-chemo |
96366 | Each additional hour beyond first |
96413 | Not appropriate — lecanemab is non-chemo |
Modifier rule: One of JZ or JW must be on every J0174 claim (CMS 7/1/2023 single-dose container policy). JW is common because of weight-based dosing.
APOE4 risk tiers (one-time CPT 81401)
| Genotype | Freq | ARIA-E | Symptomatic |
|---|
| Noncarrier | ~25% | ~9% | Lower |
| Heterozygote | ~60% | ~11% | Intermediate |
| Homozygote | ~15% | ~33% | Substantially higher |
APOE genotype is one-time, pre-treatment; document counseling in chart.
ICD-10
| Code | For |
|---|
G30.0 | AD with early onset (<65) |
G30.1 | AD with late onset (most pts) |
G30.8 / G30.9 | Other / unspecified AD |
G31.84 | MCI, so stated (MCI due to AD) |
F02.80 / F02.81 | Dementia in other diseases (use w/ G30.x) |
F02.A11 / F02.A4 | AD-associated mild dementia (FY24+) |
F02.B11 / F02.B4 | Moderate — reassess continuation |
Indication restricted to MCI or mild dementia stage AD with confirmed amyloid pathology.
CMS CED — required for Medicare
- NCD 210.20 mandates Coverage with Evidence Development
- Enroll patient in CMS-approved registry (most use Alzheimer's Disease Patient Registry via NACC)
- Document registry enrollment ID in chart and on PA
- Pre-tx workup: amyloid PET or CSF + APOE genotype + baseline MRI + cognitive staging
No CED enrollment = no Medicare coverage. Hard prerequisite.
Payer requirements (May 2026)
| Payer | PA | Notable |
|---|
| Medicare (NCD 210.20) | CED | Registry enrollment ID required |
| UnitedHealthcare | Yes | Aligns with FDA label; site-of-care steering |
| Aetna | Yes | Specialist prescriber typical (neuro/geri) |
| Cigna | Yes | MMSE thresholds (e.g., 22–30) per plan |
| BCBS plans | Yes | Generally aligned with FDA label |
All payers require amyloid biomarker, APOE genotype, baseline MRI, MCI/mild dementia stage.
Medicare reimbursement (Q2 2026)
| Field | Value |
|---|
| ASP + 6% | $1.336 / mg (eff. 4/1 – 6/30/2026) |
| 70 kg dose (700 mg) | $935.20 |
| 80 kg dose (800 mg) | $1,068.80 |
| 90 kg dose (900 mg) | $1,202.40 |
| Annual 70 kg (26 doses) | ~$24,315 |
| Annual 90 kg (26 doses) | ~$31,262 |
Site of care
| Setting | POS | Notes |
|---|
| Neurology / memory clinic | 11 | MRI co-location matters |
| Ambulatory infusion suite | 49 | Common |
| Hospital outpatient | 22 / 19 | Common in early adopters |
| Patient home | 12 | Generally not used (ARIA monitoring) |
Patient assistance — Eisai
- Phone: 1-833-453-7362 (1-833-4LEQEMBI) — Eisai Direct Patient Support
- Leqembi Co-Pay Program: commercial copay support (excludes Medicare/Medicaid/federal)
- Eisai Patient Assistance Program: free product for uninsured/underinsured
- Foundations: PAN, HealthWell — verify open AD funds quarterly
- Web: leqembi.com