Bafiertam — CareFirst (Caremark)

Initial criteria

• Diagnosis of a relapsing form of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse) OR clinically isolated syndrome
• Medication must be prescribed by or in consultation with a neurologist
• Member will not use Bafiertam 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 Bafiertam

Approval duration

12 months