Extavia — CareFirst (Caremark)
Relapsing forms of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse)
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 the requested medication concomitantly with other disease modifying multiple sclerosis agents (Note: Ampyra and Nuedexta are not disease modifying)
Reauthorization criteria
- Member is experiencing disease stability or improvement while receiving the requested medication
Approval duration
12 months