teriflunomide — Highmark
Secondary progressive multiple sclerosis
Preferred products
- teriflunomide (generic)
Initial criteria
- age ≥ 18 years
- Diagnosis of multiple sclerosis (ICD-10: G35) classified as clinically isolated syndrome OR relapsing-remitting disease OR secondary progressive disease
- If the request is for brand Aubagio, the member has experienced therapeutic failure or intolerance to generic teriflunomide
Reauthorization criteria
- Prescriber attests that the member has experienced a therapeutic response defined as disease stability OR disease improvement OR delayed disease progression
- If the request is for brand Aubagio, the member has experienced therapeutic failure or intolerance to generic teriflunomide
Approval duration
24 months