Rebif (interferon beta-1a subcutaneous injection − EMD Serono) — Cigna

Initial criteria

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

Reauthorization criteria

• Patient has a relapsing form of multiple sclerosis; AND
• Patient meets ONE of the following (a or b):
• a) 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, achievement of NEDA-3 or NEDA-4, improvement on FSIQ-RMS, 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
• b) 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
• The medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Approval duration

1 year