Avonex (interferon beta-1a intramuscular injection – Biogen) — Cigna

Relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease)

Initial criteria

Patient has a relapsing form of multiple sclerosis; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Patient has a relapsing form of multiple sclerosis; AND
Patient experienced a beneficial clinical response when assessed by at least one objective measure (e.g., stabilization or reduced worsening in disease activity as evaluated by MRI, stabilization or reduced worsening on EDSS score, achievement in criteria for NEDA-3 or NEDA-4, improvement on FSIQ-RMS scale, reduction or absence of relapses, improvement or maintenance on six-minute walk test or 12-Item MS Walking Scale, improvement on MSFC score, attenuation of brain volume loss); OR
Patient experienced stabilization, slowed progression, or improvement in at least one symptom such as motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or pain/numbness/tingling sensation; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

1 year