Multiple Sclerosis Drug Therapy
interferon beta 1a (Avonex), interferon beta 1b (Betaseron, Extavia), interferon beta 1a (Rebif, Rebif Rebidose), glatiramer (Copaxone, Glatopa), peginterferon beta 1a (Plegridy)
SELF ADMINISTRATION
Indications for Prior Authorization:
- Relapsing remitting multiple sclerosis (RRMS)
- Secondary progressive multiple sclerosis (SPMS)
Avonex, Betaseron, Copaxone 40mg, Glatopa, Plegridy and Rebif are preferred disease modifying agents for the treatment of multiple sclerosis when all the criteria below are met.
Patients must meet the following criteria for the indications above:
- Diagnosis confirmed by a neurologist, AND
- 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
Dosing:
- 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, Rebif Rebidose) - up to 44 mcg SC three times per week
- glatiramer (Copaxone, Glatopa) - 20 mg SC daily OR 40 mg 3 times per week
- peginterferon (Plegridy) - maintenance: 125 mcg SC every 14 days
Approval:
- Initial approval for one year
- Renew for one year if patient has clinical response
Last review date: December 1, 2014