Amiveve® (alefacept)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J0215

Benefit: Medical

Notes: Per 10mg; biologic treatment for moderate to severe chronic plaque psoriasis.

Length of initial authorization: 3 months.  

Length of continuation authorization: 3 months. Two courses of therapy must be separated by at least 3 months.

Criteria for coverage:

  • Diagnosis of chronic moderate to severe plaque psoriasis affecting > 10% of BSA (unless hands, feet, head and neck, or genitalia)
  • Documented trial of one topical agent, one systemic treatment, and phototherapy
  • Once criteria are met, review for annual renewal of authorization. You should not need to resubmit documentation.