peginterferon beta-1a — CareFirst (Caremark)
Clinically isolated syndrome of multiple sclerosis
Initial criteria
- Member has a diagnosis of a relapsing form of multiple sclerosis (including relapsing-remitting disease 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 Plegridy concomitantly with other disease modifying multiple sclerosis agents (Ampyra and Nuedexta are not disease modifying)
Reauthorization criteria
- Member is experiencing disease stability or improvement while receiving Plegridy
Approval duration
12 months