Multiple Sclerosis Drug Therapy

interferon beta 1a (Avonex), interferon beta 1b (Betaseron, Extavia), interferon beta 1a (Rebif), glatiramer (Copaxone), peginterferon beta 1a (Plegridy)


Indications for Prior Authorization:

  • Relapsing remitting multiple sclerosis (RRMS)
  • Secondary progressive multiple sclerosis (SPMS)

Patients must meet the following criteria for the indications above:

  • None of these drugs may be used in combination with each other or any other disease modifying therapy including natalizumab (Tysabri), mitoxantrone (Novantrone), alemtuzumab or fingolimod (Gilenya)
  • Any condition not listed above does not meet WHA criteria for approval


  • interferon beta 1a (Avonex) - up to 30 mcg IM once per week
  • interferon beta 1b (Betaseron, Extavia) - up to 0.25 mg SC every other day
  • interferon beta 1a (Rebif) - up to 44 mcg SC three times per week
  • glatiramer (Copaxone) - up to 20 mg SC daily
  • peginterferon (Plegridy) - 125 mcg SC every 14 days


  • Initial approval for one year
  • Renew for one year if patient has clinical response



Last review date: December 1, 2014

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