Quick answer
J0174
What Medicare pays for Leqembi (2026 Q4)
2026 Q4 payment limit per billing unit for Leqembi’s HCPCS code (how ASP + 6% works):
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J0174 | Lecanemab-irmb, for iv inj | 1 mg | $1.361 |
CMS ASP Drug Pricing File, 2026 Q4. Leqembi patient out-of-pocket estimate →
Worked billing example for Leqembi
A concrete, paste-checkable example using J0174’s own billing-unit basis and vial sizes — not a hypothetical.
| Scenario | 700 mg dose — 10 mg/kg IV q2wk for a 70 kg reference patient |
| Dose administered | 700 mg |
| Billing unit basis | 1 unit = 1 mg |
| Billing units (dose ÷ unit basis, rounded up) | 700 units of J0174 |
| Vial combination drawn (min-waste plan) | 1 × 500 mg vial + 1 × 200 mg vial |
| Discarded (waste) | None |
| Wastage modifier (JW / JZ) | Bill all 700 units on a single line with JZ (attests zero drug discarded). JW vs JZ, with examples → |
| Medicare allowable (ASP + 6%, 2026 Q4) | 700 units × $1.361/unit = $952.70 |
Allowable, not paid: sequestration and the covered diagnosis still apply.
Dose source: drugs/leqembi.html — FAQ: "For a 70 kg patient: 700 mg = 700 units.". Different dose or drug? Compute your own dose → or estimate the full cost & patient out-of-pocket →.
Leqembi (HCPCS J0174) is paid under Part B only when the claim’s ICD-10 code is one the MAC accepts; otherwise expect a CO-50 denial. How Part B drug coverage is decided →
Covered ICD-10 diagnoses for Leqembi
The 4 FDA-approved indications for J0174, grouped by condition — filter to find a code.
Alzheimer Disease — 4 diagnoses (applies to J0174)
Diseases of the nervous system (4)
| ICD-10 | Covered diagnosis |
|---|---|
| G30.0 | Alzheimer disease with early onset |
| G30.1 | Alzheimer disease with late onset |
| G30.8 | Other Alzheimer's disease |
| G30.9 | Alzheimer disease, unspecified |
What commercial payers require for Leqembi
Medicare Part B is only half the answer — most Leqembi claims are adjudicated by a commercial plan with its own medical policy. Below is what 21 commercial payers publish for Leqembi, read from each payer's own policy document. 20 of 20 that state a position require prior authorization (1 do not say clearly, so confirm those on the call), and 3 run a site-of-care program that can push the infusion out of the hospital outpatient setting.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | Site of Care Utilization Management Policy applies | 2 | 2026-01-27 |
| Anthem / Elevance policy ↗ | Required | — | — | 2 | 2025-10-07 |
| BCBS Federal Employee Program policy ↗ | Required | — | — | 2 | 2025-07-01 |
| BCBS Kansas policy ↗ | Required | — | — | 2 | — |
| BCBS Massachusetts policy ↗ | Required | — | — | 2 | 2026-01-15 |
| BCBS Minnesota policy ↗ | Required | — | — | 2 | 2025-10-02 |
| BCBS Mississippi policy ↗ | Required | — | — | 2 | — |
| BCBS South Carolina policy ↗ | Unclear — confirm on the call | — | — | 2 | — |
| BCBS Tennessee policy ↗ | Required | — | — | 2 | 2023-05-02 |
| Blue Shield of California policy ↗ | Required | — | — | 2 | 2026-04-01 |
| Capital BlueCross policy ↗ | Required | — | — | 2 | 2025-10-02 |
| CareFirst BCBS policy ↗ | Required | — | — | 1 | — |
| Centene / Ambetter policy ↗ | Required | — | — | 2 | 2023-01-06 |
| Cigna policy ↗ | Required | — | — | 2 | 2026-08-15 |
| Florida Blue policy ↗ | Required | — | — | 2 | 2026-06-01 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Required | — | Site-of-care program applies | 2 | 2025-08-15 |
| HMSA (BCBS Hawaii) policy ↗ | Required | — | — | 2 | 2025-02-01 |
| Premera Blue Cross policy ↗ | Required | — | — | 2 | 2026-07-01 |
| Regence BCBS policy ↗ | Required | — | Leqembi (lecanemab) coverable under the medical benefit | 2 | 2026-04-01 |
| UnitedHealthcare policy ↗ | Required | — | — | 2 | 2026-04-01 |
| Wellmark BCBS policy ↗ | Required | — | — | 2 | 2023-06-01 |
What Leqembi payers put in writing
Quoted from the medical policies linked above — 24 distinct requirements across 21 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
Member is 50 years of age or older
— Aetna, BCBS Tennessee and 2 other payers policy ↗Clinical Dementia Rating-Global Score (CDR-GS) of 0.5 or 1
— Aetna, BCBS Tennessee, Wellmark BCBS policy ↗This medication must be prescribed by or in consultation with a geriatrician, neurologist, psychiatrist, or neuropsychiatrist
— BCBS Tennessee, CareFirst BCBS, HMSA (BCBS Hawaii) policy ↗Leqembi will not be used in combination with any other amyloid beta-directed antibodies (e.g., aducanumab, donanemab).
— Aetna, BCBS Tennessee policy ↗Patient must not be treated concurrently with any other anti-amyloid therapy [Aducanumab-awwa]
— BCBS Kansas, BCBS South Carolina policy ↗This medication must be prescribed by or in consultation with a geriatrician, neurologist, psychiatrist, or neuropsychiatrist.
— Aetna policy ↗
Prior authorization
Submission of the following information is necessary to initiate the prior authorization review
— BCBS Tennessee, CareFirst BCBS policy ↗Precertification of lecanemab-irmb (Leqembi) is required of all Aetna participating providers and members in applicable plan designs.
— Aetna policy ↗Prior approval is required to ensure the safe, clinically appropriate, and cost-effective use of Leqembi
— BCBS Federal Employee Program policy ↗Coverage for Leqembi IV (lecanemab) or Kisunla (donanemab) may be considered MEDICALLY NECESSARY for the treatment of Alzheimer’s Disease when ALL the following criteria are met.
— BCBS Massachusetts policy ↗Prior authorization validity will be provided initially for 6 months.
— BCBS Minnesota policy ↗The following condition(s) require Prior Authorization/Preservice.
— Blue Shield of California policy ↗
Quantity and frequency limits
The dosage does not exceed 10 mg/kg IV every 14 days
— Florida Blue policy ↗1200 billable units (1200 mg) every 14 days
— Capital BlueCross policy ↗Leqembi IQLIK will not be used within the initial 18 months of therapy.
— CareFirst BCBS policy ↗
Dosing rules
Recommended starting dosage is 10 mg/kg once every 2 weeks administered after dilution as an IV infusion over approximately one hour.
— Aetna policy ↗In Study 1, 856 patients were randomized to receive one of 5 doses (161 of which were randomized to the recommended dosing regimen of 10 mg/kg every two weeks) of Leqembi or placebo (n=247).
— HCSC (IL/TX/OK/NM/MT) policy ↗Dose does not exceed 10 mg/kg every 2 weeks.
— Centene / Ambetter policy ↗10 mg per kilogram of body weight every 2 weeks
— UnitedHealthcare policy ↗10 mg/kg every 2 weeks dose
— Wellmark BCBS policy ↗
Reauthorization / continuation
Length of Approval 12 months unless otherwise stated in criteria below.
— BCBS Massachusetts policy ↗Renewal: Prior authorization validity may be renewed every 12 months thereafter.
— Capital BlueCross policy ↗
Site-of-care restrictions
Site of Care Utilization Management Policy applies.
— Aetna policy ↗Leqembi (lecanemab) coverable under the medical benefit
— Regence BCBS policy ↗
Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.
How to bill Leqembi
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J0174. Matching codes, units and JZ/JW wastage →
Which policy governs Leqembi
No drug-specific LCD or Article — see the note at the top of this page. Find your MAC → What an LCD, an Article and an NCD each govern →
If a claim for Leqembi is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J0174, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Leqembi covered by Medicare?
- Only under National Coverage Determination 200.3. Covered only under coverage with evidence development: the patient must be enrolled in a CMS-approved study or registry. Outside one, Medicare does not cover it. None of the 8 Medicare Administrative Contractors lists Leqembi (J0174) as self-administered.
- What diagnoses are covered for Leqembi (J0174)?
- Medicare publishes no drug-specific covered-diagnosis list for J0174. The 4 ICD-10 codes here are the FDA-approved indications; an off-label use needs approved-compendium support (DrugDex, NCCN) to be payable.
- Which Medicare policy covers Leqembi?
- National Coverage Determination 200.3 (Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD)). Covered only under coverage with evidence development: the patient must be enrolled in a CMS-approved study or registry. Outside one, Medicare does not cover it. There is no drug-specific LCD or Billing & Coding Article.
- Why was my Leqembi claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J0174. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Leqembi's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Leqembi cost & patient owe →Source & verification
- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Leqembi — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Leqembi prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — NCD 200.3 governs coverage; there is no drug-specific LCD or Billing & Coding Article, which is why the FDA-indicated codes above are the working list
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-09-21; we re-verify against CMS quarterly).
- Notes
- ICD-10-CM is public domain; CPT® (AMA) is intentionally not listed. Reference, not billing advice — built from the CMS Coverage API per our methodology; corrections to editorial@carecostestimate.com.