Bafiertam — CareFirst (Caremark)
Relapsing forms of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse)
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