CurrentColorado Rocky Mountain Health PlansPolicy CSOH2026D0023.D

Lemtrada (alemtuzumab) — Medical Benefit Drug Policy (Ohio only)

Clinical coverage and authorization guidance for Lemtrada (alemtuzumab) under the medical benefit for Ohio members of Colorado Rocky Mountain Health Plans (applies to Ohio only).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyLemtrada (alemtuzumab) — Medical Benefit Drug Policy (Ohio only)

Policy CodePolicy CSOH2026D0023.D

Change TypeRoutine review — no material changes

Effective DateJun 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests using current InterQual criteria and reference HCPCS code J0202.

SourceLink

POLICY UPDATE CHANGES

06/01/2026 routine review; no content changes and previous policy version CSOH2025D0023.C archived.

J0202HCPCS code

OhioApplies to

InterQualClinical criteria

Coverage Criteria

Medical Necessity (Initial and ongoing coverage determined by InterQual)

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Listing of a billing code in this policy is provided for reference only and does not imply that the service described by the code is a covered or non‑covered health service. Benefit coverage and reimbursement are determined by applicable federal, state, and contractual requirements and other plan terms; inclusion of a code here does not guarantee payment or authorization.

This policy applies only to Ohio. Services that do not meet the InterQual criteria for Lemtrada (alemtuzumab) or services identified as unproven under Ohio Administrative Code 5160‑1‑01 will be evaluated and may be considered not medically necessary and therefore not covered. For clinical coverage determinations, refer to the current InterQual guideline for Lemtrada.

Provider Actions & Authorization

Prior Authorization

InterQual-based prior authorization

Prior authorization and coverage determinations for alemtuzumab (Lemtrada) are governed by the InterQual® guideline: CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada). Providers must request authorization using HCPCS code J0202 (Injection, alemtuzumab, 1 mg).

HCPCS: J0202 — Injection, alemtuzumab, 1 mg (Lemtrada)

Step Therapy

Step therapy and sequencing

Step therapy, sequencing, and prior treatment requirements follow the InterQual guideline. Providers should confirm the current InterQual criteria release for any sequencing or prior-therapy rules that apply to initial or continuation therapy.

Documentation Required

Documentation expectations

When submitting prior authorization requests, providers must include documentation that addresses federal, state (Ohio Administrative Code), and contractual coverage requirements. Supporting clinical records should reference relevant InterQual criteria items and include diagnosis, prior treatments, treatment rationale, and any applicable objective test results or specialist notes.

Reference InterQual: CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada)
Include diagnosis, prior treatments, treatment rationale, objective test results, and specialist notes
Ensure documentation meets federal, Ohio Administrative Code (OAC) and contractual requirements

Denial Risk

Denial triggers

Requests that do not meet InterQual criteria may be denied as not meeting medical necessity. Additionally, services described in this policy as unproven or subject to limits will be evaluated under Ohio Administrative Code 5160-1-01 and may be denied if they do not meet those standards.

Background

Lemtrada (alemtuzumab) is a monoclonal antibody that is stated in this policy as proven and medically necessary for the treatment of certain conditions when the patient meets the criteria in the current InterQual guideline. Medical necessity determinations for both initial and ongoing therapy are made according to the InterQual® criteria titled "CP: Specialty Rx Non‑Oncology, Alemtuzumab (Lemtrada)."

Definitions

InterQual definition / reference

DefinitionInterQual: proprietary, evidence‑based clinical criteria used to determine medical necessity; see the current InterQual guideline 'CP: Specialty Rx Non‑Oncology, Alemtuzumab (Lemtrada)' for the specific Lemtrada criteria.

PurposePrimary source for medical necessity determinations for Lemtrada (alemtuzumab); initial and ongoing coverage are governed by the current InterQual guideline.

Where to find detailsRefer to the current release of the InterQual guideline for Lemtrada (CP: Specialty Rx Non‑Oncology, Alemtuzumab [Lemtrada]) for exact clinical eligibility, sequencing, and continuation criteria.

Policy linkageThis policy defers to InterQual for clinical coverage criteria; services meeting InterQual criteria are considered proven and medically necessary per this policy.

ScopeApplied to medical necessity assessments under this Lemtrada policy for covered populations; see policy header for state applicability (Ohio).

Initial Therapy Criteria

Initial Therapy — Initial coverage requires meeting InterQual initial therapy criteria

Initial coverage requires meeting InterQual initial therapy criteria.

Initial therapy criteria: Patient meets initial criteria as defined in the current InterQual guideline for alemtuzumab (Lemtrada)see InterQual

Continuation Therapy Criteria

Continuation Therapy — continuation based on ongoing fulfillment of InterQual criteria

Continuation of therapy coverage is based on ongoing fulfillment of InterQual criteria.

Ongoing criteria: Continued coverage requires documentation that the patient continues to meet InterQual continuation criteria for Lemtradasee InterQual

Step	Requirement / Action	Reference
1	Refer to the current InterQual guideline for any step therapy or prior treatment failure requirements before Lemtrada (alemtuzumab) is authorized.	InterQual: CP: Specialty Rx Non-Oncology, Alemtuzumab (Lemtrada)

Site of Care

Note

Infusion center site-of-care requirements follow InterQual and federal/state/contract rules

Site-of-care considerations, including use of infusion centers, must follow federal, state, contractual rules and InterQual recommendations where applicable; apply any site restrictions in accordance with those authorities.

Confirm infusion center site-of-care requirements align with InterQual guidance and applicable federal/state/contractual rules.