CareCost Prior authorization
Required
Check what the payer requires before you schedule Leqembi.
Prior authorization · confirmed amyloid pathology · covered dosing · site of care
20 payer policy sets · 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 Leqembi is purchased or infused for this member.
Precertification of lecanemab-irmb (Leqembi) is required of all Aetna participating providers and members in applicable plan designs.
Covered under ICD-10 G31.84.
mild cognitive impairment due to AD
What opens in CareCost
Aetna · Leqembi · 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 · Leqembi · 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 Leqembi coverage requirements across 20 payer policy sets.
Aetna · Anthem / Elevance · UnitedHealthcare · Regence · Premera · BCBS plans + more
Coverage clearance is only the first step.
CareCost carries the same patient through the entire workflow.
Finish this patient’s estimate →18 of 20 commercial payers require prior authorization, across 175 rules. Clinical-prerequisite, quantity-limit and reauthorization rules vary by plan.
18 require PA · 20 have clinical criteria · 3 restrict site of care · 1 of 20 requires no prior anti-amyloid antibody
18 of the 20 payers in CareCost’s Leqembi corpus require an approval on file before the drug is purchased or infused.
Two ICD-10 families are covered: mild cognitive impairment due to Alzheimer’s disease (G31.84, 19 of 20 payers) and mild Alzheimer’s disease dementia (G30.x, all 20 payers).
Clinical-prerequisite rules are the largest category in the corpus: 83 of 175. They document the qualifying MCI or mild-dementia stage and the amyloid confirmation ahead of the first infusion.
12 dosing rules converge on the label’s starting regimen. Aetna’s policy states it directly: “Recommended starting dosage is 10 mg/kg once every 2 weeks administered after dilution as an IV infusion over approximately one hour.”
Three payers cap the dose or the interval. Florida Blue: “The dosage does not exceed 10 mg/kg IV every 14 days.” Capital BlueCross: “1200 billable units (1200 mg) every 14 days.” CareFirst BCBS: “Leqembi IQLIK will not be used within the initial 18 months of therapy.”
Three payers document a renewal period. BCBS Massachusetts: “Length of Approval 12 months unless otherwise stated in criteria below.” Capital BlueCross: “Renewal: Prior authorization validity may be renewed every 12 months thereafter.” BCBS South Carolina, for mild Alzheimer’s disease dementia: “Member meets original authorization criteria. Member has been evaluated for evidence of amyloid-related imaging abnormalities (ARIA) on MRI prior to the 5th dose…”
Three payers restrict where the infusion can happen. Aetna: “Site of Care Utilization Management Policy applies.” Regence: “Leqembi (lecanemab) coverable under the medical benefit.” HCSC: “J0174 Lecanemab-irmb Leqembi®.”
Leqembi’s 20-payer corpus converges on the same clinical picture before it pays: confirmed amyloid pathology, an early symptomatic stage, a baseline MRI and, for one payer, no prior anti-amyloid antibody.
| Requirement | What the corpus documents | Basis |
|---|---|---|
| Confirmed amyloid pathology | PET or CSF evidence of amyloid beta pathology before the first infusion | Clinical-prerequisite rules, 83 of 175 |
| Disease stage | MCI or mild dementia stage, documented on a cognitive-scale range | Clinical-prerequisite rules, 83 of 175 |
| Baseline MRI | A recent brain MRI before treatment starts, then a scheduled MRI series during treatment | Label (DailyMed 9d1ff786…) |
| ApoE ε4 genotyping | Before treatment, where the payer’s policy incorporates the label | Label |
| No other anti-amyloid antibody | 1 of 20 payers — BCBS Massachusetts | Clinical-prerequisite quote, below |
Coverage with evidence development, NCD 200.3, governs Part B payment for this drug. The prescriber enrolls the patient in a CMS-approved registry — a CareCost Leqembi reference page names NACC’s Alzheimer’s Disease Patient Registry as the one most providers use — and the registry enrollment plus the documented amyloid result are claim facts. NCD 200.3 is a national determination, so the registry and biomarker conditions come from the NCD itself.
No registry, no payment: a claim submitted without registry enrollment on file is not covered.
It depends on the payer and plan. In CareCost’s Leqembi corpus, 18 of 20 commercial payers require prior authorization, and all 20 apply clinical coverage criteria before treatment. Check this patient’s payer →
Every one of the 20 Leqembi (J0174) policies asks for the same core: confirmed amyloid pathology, the mild cognitive impairment or mild dementia stage, and a baseline MRI, and 18 of the 20 require prior authorization. CareCost turns the applicable policy into a patient-level checklist covering the covered indication, dosing, and, for a smaller group of payers, a quantity limit or reauthorization date, each with the exact policy language behind it. Open patient clearance →
Yes. Medicare pays for Leqembi under NCD 200.3, coverage with evidence development. The prescriber enrolls the patient in a CMS-approved registry and documents the amyloid result; without registry enrollment, Medicare does not pay the claim. See Original Medicare ↑
Coverage with evidence development requires enrollment in a CMS-approved registry before Medicare pays — CareCost’s Leqembi reference page names NACC’s Alzheimer’s Disease Patient Registry as the one most providers use. No registry, no payment. See Original Medicare ↑
CareCost’s corpus doesn’t break ApoE genotyping out as its own rule — it sits inside the 83 clinical-prerequisite rules across the 20 payers, which the patient checklist opens individually. Check this patient’s payer →
It varies by payer. In CareCost’s corpus, BCBS Massachusetts documents a 12-month approval length, and Capital BlueCross allows renewal every 12 months thereafter; other payers reauthorize on documented response. Check this patient’s payer →
Data current: payer policies Aug 2026 · reviewed dates come from each payer
Payer medical and specialty-drug policies · prior-authorization criteria · site-of-care policies · clinical-prerequisite criteria. Medicare coverage from CMS NCD 200.3. Every CareCost requirement links back to its source policy.