Multiple Sclerosis Drug Therapy
interferon beta 1a (Avonex)
interferon beta 1b (Betaseron, Extavia)
interferon beta 1a (Rebif)
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.
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: December 2014 Reviewed: