Bafiertam — Blue Cross Blue Shield of Oklahoma

Preferred products

• teriflunomide
• Glatopa
• glatiramer
• fingolimod
• dimethyl fumarate

Initial criteria

• Patient has ≥1 gadolinium enhancing lesion on MRI OR significant increase in T2 lesion load compared with previous MRI OR has been treated with at least 3 multiple sclerosis agents from different drug classes (documentation required)
• If requested agent is Aubagio (teriflunomide): prescriber obtained transaminase and bilirubin levels within 6 months prior to initiating treatment
• If requested agent is Gilenya or Tascenso ODT (fingolimod): prescriber performed an electrocardiogram within 6 months prior to initiating treatment
• If patient has an FDA labeled indication: patient age is within FDA labeling OR there is support for use of the requested agent for the patient’s age
• If requested agent is a brand product with a corresponding generic listed below, ONE of the following: A. patient currently stable on brand; OR B. intolerance or hypersensitivity to corresponding generic; OR C. FDA labeled contraindication to generic; OR D. generic discontinued due to lack of efficacy/adverse reaction; OR E. expected ineffectiveness, adherence barrier, or harm from generic; OR F. corresponding generic not in best interest of patient; OR G. patient tried another prescription drug in same class discontinued for lack of efficacy/adverse event; OR H. there is support for use of requested agent over generic
• Prescriber is a specialist in neurology or has consulted a neurologist
• ONE of the following: (A) patient will NOT use in combination with another disease-modifying agent for same indication OR (B) combination use only with Mavenclad when supported (e.g., relapse between cycles)
• Patient does not have any FDA labeled contraindications to requested agent
• Special approvals for BCBS MT fully insured or MT HIM members < age 18 years meeting evidence-based criteria OR for Ohio fully insured/HIM Shop members meeting compendia or literature support (two peer-reviewed articles or compendia levels approved)

Reauthorization criteria

• Patient previously approved for requested agent through plan’s Prior Authorization process
• If requested agent is brand product with corresponding generic, one of: A. currently stable on requested agent; OR B. intolerance or hypersensitivity to generic; OR C. labeled contraindication to generic; OR D. generic discontinued due to lack of efficacy/adverse event; OR E. expected ineffectiveness/adherence barrier/harm from generic; OR F. generic not in best interest of patient; OR G. tried another similar drug discontinued due to lack of efficacy/adverse event; OR H. support for use of requested agent over generic
• Patient has had clinical benefit with requested agent
• Prescriber is a specialist in neurology or has consulted a neurologist
• Patient will not use requested agent in combination with another disease-modifying agent except possibly with Mavenclad supported by documentation
• Patient does not have any FDA labeled contraindications to requested agent

Approval duration

12 months