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Aubagio (teriflunomide) — Blue Cross Blue Shield of New Mexico

Relapsing forms of multiple sclerosis

Preferred products

  • Avonex (interferon β-1a)
  • Betaseron (interferon β-1b)
  • dimethyl fumarate
  • glatiramer
  • Glatopa (glatiramer)
  • Kesimpta (ofatumumab)
  • Mayzent (siponimod)
  • Plegridy (peginterferon β-1a)
  • Rebif (interferon β-1a)
  • teriflunomide
  • Zeposia (ozanimod)

Initial criteria

  • ONE of the following: the requested agent is eligible for continuation of therapy AND the prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed OR the following criteria for new therapy must be met.
  • For patients with relapsing forms of multiple sclerosis:
  • ONE of the following: the requested agent is a preferred agent OR the requested agent is a non-preferred agent AND the prescriber states the patient is currently being treated and stable on the requested agent [chart notes required]; OR
  • Patient age ≤ 17 years AND ONE of the following: the requested agent is a brand agent without an equipotent generic strength (Gilenya 0.25 mg, Tascenso ODT 0.25 mg) OR the patient previously tried and had an inadequate response to generic fingolimod OR discontinued generic fingolimod due to lack of efficacy/effectiveness/adverse event [chart notes required] OR has intolerance or hypersensitivity to generic fingolimod [medical records required] OR has an FDA labeled contraindication to generic fingolimod [medical records required] OR generic fingolimod is expected to be ineffective or unsafe or not in the best interest of the patient based on medical necessity OR the patient has tried another drug in the same class that was discontinued for lack of efficacy/adverse event OR if requested agent is Tascenso ODT 0.5 mg, there is support for its use over generic fingolimod (e.g., swallowing difficulties).
  • Patient age ≥ 18 years AND BOTH of the following:
  • ONE of the following: patient has tried and had inadequate response to TWO preferred agents that are FDA labeled for the indication (medical records required) OR the two preferred agents were discontinued due to lack of efficacy/effectiveness/adverse event [chart notes required] OR intolerance/hypersensitivity to TWO preferred agents [chart notes required] OR FDA labeled contraindication to ALL preferred agents [chart notes required] OR two preferred agents expected to be ineffective / unsafe / medically not in best interest based on patient characteristics [chart notes required] OR patient has tried another drug in the same class as two preferred agents that was discontinued due to lack of efficacy/adverse event [chart notes required].
  • AND If requested agent is Tascenso ODT 0.5 mg, ONE of the following must be met: tried and inadequate response to generic fingolimod OR generic fingolimod discontinued for lack of efficacy/adverse event OR intolerance or hypersensitivity to generic fingolimod not expected with requested agent OR contraindication to generic fingolimod not expected with requested agent OR generic fingolimod expected to be ineffective / unsafe / medically not in best interest / cause adherence barrier or harm OR support for requested agent over generic fingolimod (e.g., swallowing difficulty).
  • Patient has highly active MS disease activity defined as ≥ 2 relapses in the previous year (medical records including chart notes required).

Reauthorization criteria

  • Patient was previously approved for requested agent through plan’s Prior Authorization process AND has had clinical benefit with the requested agent.
  • A complete CBC with differential including lymphocyte count has been performed AND lymphocyte count ≥ 800 cells/microliter.
  • Prescriber is a neurologist or has consulted with a specialist in the area of the patient’s diagnosis.
  • ONE of the following: patient will NOT be using requested agent in combination with additional disease modifying agent for MS OR there is support for combined DMA use (e.g., relapse between cycles).
  • Patient does NOT have any FDA labeled contraindication to the requested agent.
  • It has been at least 35 weeks but not more than 67 weeks since the last dose of the requested agent.
  • Prescriber has provided the number of courses completed AND patient has NOT completed 2 courses (each course = 2 cycles of 4–5 days each).
  • Requested dose does NOT exceed the maximum FDA labeled dose for patient’s weight.

Approval duration

12 months