Avonex (interferon beta-1a) — Highmark
multiple sclerosis (ICD-10: G35), classified as clinically isolated syndrome, relapsing-remitting disease, or active secondary progressive disease
Initial criteria
- age ≥ 18 years
- diagnosis of multiple sclerosis (ICD-10: G35) classified as one of the following: clinically isolated syndrome OR relapsing-remitting disease OR active secondary progressive disease
Reauthorization criteria
- prescriber attests that the member has experienced a therapeutic response defined as one of the following: disease stability OR disease improvement OR delayed disease progression
Approval duration
12 months