Multiple Sclerosis Therapy
| Covered Uses: |
All FDA-approved indications not otherwise excluded from Part D. Additional off-label coverage is provided for treatment at the time of a first demyelinating event. |
| Exclusion Criteria: |
Treatment of primary progressive MS is not covered. Combination therapy with a beta interferon product, Gilenya, or Copaxone is not covered. |
| Required Medical Information: |
For relapsing forms of multiple sclerosis: Patient must still either be able to walk at least a few steps or alternatively must have some functional arm/ hand use consistent with performing activities of daily living. For Rebif only, patients must be already receiving Rebif or have experienced intolerance/failure with glatiramer (Copaxone), interferon beta-1b (Betaseron) or Interferon beta-1a (Avonex). |
| Age Restrictions: |
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| Prescriber Restrictions: |
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| Coverage Duration: |
12 months |
| Other Criteria: |
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Last Modified on 12/19/2012
