Extavia — Medical Mutual
multiple sclerosis
Preferred products
- generic glatiramer injection
Initial criteria
- Patient meets the standard Multiple Sclerosis – Betaseron/Extavia Prior Authorization Policy criteria
- Patient has been established on Extavia for ≥ 120 days OR
- Patient has tried generic glatiramer injection AND experienced inadequate efficacy or significant intolerance according to the prescriber (Note: Prior use of Copaxone or Glatopa also counts)
- AND Patient has tried Avonex, Betaseron, Plegridy, or Rebif AND experienced inadequate efficacy or significant intolerance according to the prescriber
Approval duration
1 year