Aubagio — CareFirst (Caremark)
Clinically isolated syndrome of multiple sclerosis
Initial criteria
- Member has a diagnosis of a relapsing form of multiple sclerosis OR clinically isolated syndrome of multiple sclerosis
- Medication is prescribed by or in consultation with a neurologist
- Member will not use the requested medication concomitantly with other disease-modifying multiple sclerosis agents (Ampyra and Nuedexta are not disease modifying)
- Authorization may be granted for pediatric members less than 18 years of age when benefits outweigh risks
Reauthorization criteria
- Member is experiencing disease stability or improvement while receiving the requested medication
Approval duration
12 months