Avonex — CareFirst (Caremark)
Clinically isolated syndrome of multiple sclerosis
Initial criteria
- Member has been diagnosed with a relapsing form of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse) OR clinically isolated syndrome of multiple sclerosis
- Medication is prescribed by or in consultation with a neurologist
- Member will not use Avonex concomitantly with other disease modifying multiple sclerosis agents (Ampyra and Nuedexta are not considered disease modifying)
Reauthorization criteria
- Member is experiencing disease stability or improvement while receiving Avonex
Approval duration
12 months