Betaseron (interferon beta-1b subcutaneous injection – Bayer) — 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 the Expanded Disability State Scale [EDSS] score, achievement in No Evidence of Disease Activity-3 [NEDA-3] or NEDA-4, improvement on clinical or functional measures) 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; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

1 year