Quick answer
J0174
What Medicare pays for Leqembi (2026 Q3)
Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J0174 | Inj, lecanemab-irmb, 1 mg | 1 mg | $1.342 |
Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →
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). What JZ/JW mean → |
| Medicare allowable (ASP + 6%, 2026 Q3) | 700 units × $1.342/unit = $939.40 |
This is Medicare’s allowable payment limit (ASP + 6%, 2026 Q3) — not a promise of what you will be paid. Actual paid amount depends on sequestration and whether the claim carries a covered diagnosis.
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 is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J0174) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).
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 20 commercial payers publish for Leqembi, read from each payer's own policy document. 18 of 20 that state a position require prior authorization, 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 ↗ | Not required | — | — | 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 |
| Florida Blue policy ↗ | Required | — | — | 2 | 2026-06-01 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Not 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 20 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?
- Yes. Leqembi (J0174) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point.
- 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?
- No drug-specific LCD or Billing & Coding Article exists for Leqembi. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- 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 — searched for “Leqembi”; no drug-specific NCD, LCD or Billing & Coding Article exists, which is why the FDA-indicated codes above are the working list
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-08-26; we re-verify against CMS quarterly).
- Code licensing
- ICD-10-CM codes are public domain (CMS/CDC). CPT® codes are AMA-copyrighted and are intentionally not listed here — see the administration-code reference for those.
- Not advice
- This is general billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.
- How we build this
- Compiled programmatically from the CMS Coverage API under a founder-led methodology maintained by Erin Rose (Founder), and reviewed against the source article with a practitioner-correction loop. See our methodology and editorial policy.
- Spotted an error?
- Email editorial@carecostestimate.com.